^ 


PERKINS  LIBRARY 

Uuke   University 


Kare  Dooks 


/   )    *      (/  J^*^A^U^-r 


>  / 


^        SYSTEM     A^/^-^^a 

SURGERY: 


OF 


BY 


BENJAMIN  BELL, 


MEMBER  OF   THE   ROYAL  COLLEGES  OF   SURGEONS    OF  EDINB0RGH  AND 

IRELAND,  ONE  OF  THE   SURGEONS  TO  THE  ROYAL  INFIRMARY, 

AND   FELLOW  OF  THE  ROYAL  SOCIETY  OF  EDINBURGH. 


ILLUSTRATED    n'lTH   COPPERPLATES. 


VOLUME    IIL 


;F.C0ND  AMERICAN,  FROM  THE  SEVENTH   EDINBURGH   EDITION, 


CORRECTED    AND    ENLARGED. 


TROY,  NEW-YORK; 


PRINTED   BY  O.  PENNIMAN  AND  CO. 


FOR  themselves;    THOMAS  AND  ANDREWS,  BOSTON;    T.  S.  ARDEN, 
NEW-YORK;    AND  J.  CONRAD  AND  CO.  PHILADELPUIA. 


1804. 


7"i 


c 


•-.  .'v 


<'^ 


<£5^ 


CONTENTS. 


CHAPTER    XXm. 

Page 
Of  HERNIiE,  -  -  -  I 

Se£t.  11.  Of  the  Bubonocele^                -  ib. 
Sed.  III.  Of  the  Hernia  Congenita,           -  2 1 
Se£l.  IV.  Of  the  Crural  or  Femoral  Hernia,  23 
Sedl.  V.  Of  the  Exomphalos,  or  Vmhilical  Rup- 
ture,            -             -             >             .  27 
Se<a.  VI.  Of  Ventral  Hernia,                -  30 
Sed.  VII.  Of  the  Hernia  of  the  Foramen  Ovale,  31 
Sea.  VIII.  (y //j^  Hernia  Cyjiica,  or  Hernia  of 
the  Urinary  Bladder,              -                   -  3* 
CHAPTER     XXIV. 
On  the  hydrocele,            -                -  36 
Sed.  I.  General  Remarks  on  the  Hydrocele,  ib. 
Seft.  II.  0/"  the  Anafarcous  Hydrocele  of  the 

Scrotum,             -                 -                  -  40 
Sedl.  HI.  Of  the  Hydrocele  of  the  Tunica  Vagi- 
nalis Tejiis,              -                          -  47 
Se£l.  IV.  Of  the  Hydrocele  of  the  Hernial  Sac,  97 
Sed.  V.  Of  the  Anafarcous  Hydrocele  of  the 

Spermatic  Cord,             -                     -  loi 
Se6l.  VI.  Of  the  Encyfied  Hydrocele  of  the  Sper- ' 

7?iatic  Cord,             -                         -  103 

CHAPTER     XXV. 

On  the  HiEMATOCELE,  -  1 10 


Page 


Iv  CONTENTS. 

CHAPTER     XXVL 
Of  the  varicocele,  circocele,  spermato- 
cele, AND  PNEUMATOCELE,  -  Il6 

CHAPTER     XXVII. 

Of  the  sarcocele,  or  schirrous  testicle,  119 

CHAPTER     XXVIII. 

Of  the  diseases  of  the  penis,             -  139 

Sea.  I.  Of  the  Phymofis,                 -  ib. 

Se6t.  II.   Of  the  Paraphymofis,                  -  142 

Sedt.  III.  Of  Amputation  of  the  Petiis,  145 
CHAPTER     XXIX. 

Of  the  stone,             -                         -  149 

Seel.  I.  General  Remarks  on  Urinary  Calculi,  ib. 

Seel.  II.  Of  bounding  or  Searching  for  the  Stone,  155 
Sedl.  III.  General  Remarks  on  the  Operation  of 

Lithotomy,                  -                          -  164 
Se6t.  IV.  Of  the  Operation  of  Lithotomy  by  the 

Leffer  Apparatus,                   -                   -  168 
Se£l.  V.  Of  Lithotomy  by   the  Greater  Appa- 
ratus,            -                  -                      '  '^I'h 
Se6l.  VI.  Of  the  High  Operation  for  the  Stone,  176 
Sed  VII.  Of  the  Lateral  Operation,  182 
Sea.  VIII.  Of  Nephrotomy,             -  215 
Sea.  IX.  Of  Stones  in  the  Urethra,         -  217 
CHAPTER     XXX. 
Of  incontinence  of  urine,                -  225 

CHAPTER      XXXI. 

Of  suppression  of  urine,             -             -  229 

CHAPTER      XXXII. 

Obstructions  in  the  urethra,         -  241 


CONTENTS.  V 

CHAPTER      XXXIII.  ^'^ 

Of  the  fistula  in  perin^o,  -  260 

CHAPTER     XXXIV. 

Of  hemorrhoids,  or  piles,  -  271 

.  CHAPTER     XXXV. 

Of  condylomatous  excrescences,  and 

similar  affections  about  the  anus,        279 
CHAPTER     XXXVI. 
Of  a  prolapsus  ani,  -  -  281 

CHAPTER     XXXVII. 
Of  an  imperforated  anus,  -  284 

CHAPTER     XXXVIII. 
Of  the  fistula  in  ano,  -  288 

CHAPTER     XXXIX. 
Of  fractures,  .  _  .  ^14 

Sect.  I.  General  Obfervaiions  on  Fradures,  ib. 

Sea.  II.  Of  Fradures  of  the  Nofe,  -  332 

Seft.  III.  Of  Fra6lurcs  of  the  Bones  of  the  Faec,  2i33 
Se6l.  IV.  Of  Fractures  of  the  inferior  Maxilla- 
ry Bones,  -  -  .  -^-jp 
Seft.  V.  Of  Fractures  of  the  Clavicles  and  Ribs  y  337 
Scd.  VI.  OfFradures  of  the  Sternum,  341 
Sea.  VII.  Of  Fradures  of  iheVeriebra,  Os  Sa- 
crum, Coccyx,  and  Ojfa  hmominata,  343 
Sea.  VIII.  OfFradurcs  of  the  Scapula,  345 
Sea.  IX.  OfFradurcs  of  the  Humerus,  346 
Sea.  X.  Of  Fradures  of  the  Bones  cf  the  Fore- 

Ar?u,  -  _  _ 

Sea.  XL    Of  Fradures  of  the  Bones  of  the 

Wrijl,  Hands,  and  Fifjgers,  -  3^2 

Sea.  XII.  Of  Fradures  cf  the  Femur  or  Thigh 
Bone,  .  ,  3^4 


349 


vi  CONTENTS. 

Page 

Sea.  XIII.  Of  Fradurcs  of  the  Patella,  361 

Sea.  XIV.   Of  Fradurcs  of  the  Bones  of  the 

Leg,  -  -  -  366 

Sea.  XV.  OfFracIures  of  the  Bones  of  the  Foot 

and  Toes,  -  -  '     -  370 

Sea.  XVI.  Of  Compound  Fractures,  371 

CHAPTER     XL. 

Of  LUXATIONS,  _.  -  -  383 

Sea.  I.  General  Remarks  on  Luxations,  ib. 

Sea.  II.  Of  LuKat'ions  of  the  Bones  of  the  Cra- 
nium, -  -  -  395 
Sea.  Ill,  Of  Luxations  cf  the  Bones  of  the  Nofe,  396 
Sea.  IV,  Of  Luxations  of  the  Loiver  "Jaw,  ib. 
Sea.  V.  Of  Luxations  of  the  Head,  -  400 
Sea.  VI,  Of  Luxations  of  the  Spine,  Os  Sa- 
crum, and  Os  Coccyx,  -  -  401 
Sea.  VII.  Of  Luxations  cf  the  Clavicles,  405 
Sea.  VIII.  Of  Luxations  cf  the  Ribs,  407 
Sea.  IX.  Of  Di/locations  of  the  Hu?}ierus  at  the 

foint  of  the  Shoidder,  -  -  409 

Sea.  X.  Of  Luxations  of  the  Fore- Arm  at  the 

Joint  cf  the  Elbow,  -     -  -  422 

Sea.  XI.  Of  Luxations  of  the  Bones  of  the  Wrijl,  425 
Sea.  XII.    Of  Luxations  of  the  Bones  cf  the 

Metacarpus  and  Fingers,  -  -       427 

Sea.  XIII.  Of  Luxations  cf  the  Femur  at  the 

Hip  Joint,  -  -  -       428 

Se^.  XIV.  Of  Luxations  of  the  Patella,  435 

Sea.  XV.  Of  Luxaiiofis  of  the  Tibia  a7id  Fibu- 
la at  the  Joint  cf  the  Knee,  -  437 


CONTENTS.  vu 

Page 

Se6l.  XVI.    Of  Luxations  of  the  Foot  at  the 

Joint  of  the  Ankle,  -  -  439 

Sea.  XVII.  Of  Luxations  of  the  Os  Gala's,  and 
other  Bones  of  the  Foot.  -  -  440 

CHAPTER     XLI. 
Of  distorted  limbs,  .  -  442 

CHi^TER     XLII. 
Of  distortions  of  the  spine,  -  448 

CHAPTER     XLIIl. 
Of  necrosis,  -  -  -  451 

CH/VPTER     XLIV. 
Of  amputation,  -  -  457 

Se£l.  I.  General  Remarks  on  the  Operation  of 

A?nputation,  -  -  ib. 

Se£t.  lis  Of  the  Caufes  which  may  render  Am- 
putation neceffary,  -  -  458 
Sect.  III.  General  Remarks  on  the  Method  of 

Amputating  Limbs,  -  -  470 

Se£t.  IV.  Of  Amputating  the  Thigh,  475 

Se6l.  V.  Of  Amputating  the  Leg,  -  492 

Se£l.  VI.  Of  Amputating  with  a  Flap,  497 

Se£t.  VII.  Of  Amputating  at  the  Hip  Joint,        499 
Se£l.  VIII.  Of  the  Flap  Operation  immediately 

above  the  Knee,  -  -  503 

Se<51:.  IX.  Of  the  Flap  Operation  below  the  Knee,  508 
Sedl.  X.    Of  Amputating  the  Foot,  Tecs,  and 

Fingers,  ...  509 

Sed.  XI.  Of  Amputating  the  Arm  at  the  Joint 

cf  the  Shoulder,  -  -  512 

Se(a.  XII.  Of  Amputating  the  Arm,  516 


Ylii  CONTENTS. 

fage 

CHAPTER     XLV. 

Of  removing  the  ends  of  bones   in   dis- 
eases of  THE  JOINTS,  -  -  517 

CHAPTER     XLVI. 

Of  issues,  -  -  -  522 

CHAPTER     XLVII. 

Of  the  INOCULATION  OF  THE  SMALLPOX,  527 

CHAPTER     XLVIII. 

Of    PREVENTING     OR     DIMINISHING     PAIN     IN 

GHIRURGICAL  OPERATIONS,  -  530 

CHAPTER  XLIX. 

Of  MIDWIFERY,  -  -  533 

Sect.  I.  General  Obfervations  on  Midwijery,         ib. 
Seft.  II.  Of  the  Cafarean  Operation,  535 

Seft.  III.  Of  the  Divifwn  of  the  Symphyfis  Pubis  538 
CHAPTER     L. 

Of  OPENING  DEAD  BODIES,  -  -  542 

CHAPTER     LI. 

Of  EMBALMING,  -  -  545 

CHAPTER     LII. 

Of  BANDAGES,  -  -  -  547 


A 

SYSTEM 

OF 

SURGERY. 


CHAPTER     XXIII. 

OF  HERNIiE, 


SECTION    II. 

Of  the  Bubonocele. 


CONJOINED  with  the  general  fymptoms  of  her- 
nia enumerated  in  the  laft  feftion,  the  particu- 
lar appearances  of  the  bubonocele,  or  inguinal  hernia, 
are,  a  foft  Ibmcwhat  elallic  tumor,  beginning  in  the 
groin,  and  defcending  by  degrees  into  the  fcrotum  in 
men,  and  labia  pudendi  in  women.  When  a  portion 
of  gut  forms  the  difeafe,  the  tumor  is  commonly  tenfe 
m  proportion  to  the  degree  of  ftrifture  in  the  opening 
of  the  tendon  ;  and  when  the  parts  inflame,  handling 
or  preflTure  always  gives  pain. 

When  it  contains  omentum  only,  the  tumor  is  both 
more  foft,  comprefliblc,  and  more  unequal,  than  when 
gut  alone  is  down  ;  the  fcrotum  becomes  more  ob* 
long  than  in  an  inteflinal  hernia  ;  and  when  the  quan- 
tity of  omentum  is  large,  it  is  alfo  much  more  weigh- 

Vol.  III.  B 


1  Of  Hernia.  Chap.  XXIII, 

ty  than  a  gut  rupture  of  the  fame  fize :  but  in  a  great 
proportion  of  cafes,  the  tumor  is  compofed  both  of 
gut  and  omentum  :  in  this  cafe  the  diftinguifhing 
fymptoms  of  each  can  never  be  fo  clearly  marked. 
Various  fymptoms  indeed  are  enumerated  by  authors 
for  diftinguifhing  the  contents  of  hernioe  ;  but  when- 
ever the  cafe  is  complicated,  every  candid  pradlitioner 
will  admit,  that  no  certainty  can  be  obtained  of  this 
till  the  tumor  is  laid  open. 

As  thefe  parts  are  hable  to  other  tumors  with  which 
the  inguinal  and  fcrotal  hernia  may  be  confounded, 
pradtitioners  fhould  be  as  much  as  poflible  acquainted 
with  the  marks  of  diftindion.  Thefe  tumors  are,, 
glandular  or  other  fwellings  in  the  groin,  whether 
from  the  venereal  difeafe  or  any  other  caufe ;  that 
fwelling  of  the  teftis  termed  hernia  humorahs ;  and 
the  different  varieties  of  hydrocele. 

The  venereal  bubo  and  other  glandular  tumors  in 
the  groin,  are  diftinguifhed  from  hernia,  not  only  by 
their  wanting  all  the  general  fymptoms  of  hernia,  but 
by  that  incompreffible  hardnefs  with  which  glandular 
fwellings  are  at  firft  attended,  and  by  the  fluctuation 
of  matter  which  in  their  fuppurated  ftate  is  obfervable. 

In  the  hernia  humoralis,  the  hardened  and  enlarged 
ftate  of  the  tefticle ;  its  being  exquifitely  painful  to 
the  touch ;  remarkably  heavy  in  proportion  to  its 
bulk  ;  and  the  fpermatic  procefs  being  commonly  free 
from  fwelling  ;  may  be  confidered  as  certain  m.arks  of 
diftinclion.  In  the  hernia  humorahs,  too,  the  intef- 
tines  are  free  and  unobftrucled,  and  the  other  general 
fymptoms  of  hernia  are  wanting. 

In  the  hydrocele  of  the  tunica  vaginalis  teftis,  the 
tumor  in  general  is  more  equal  than  in  hernia  :  in  the 
former,  it  begins  in  the  under  part  of  the  fcrotum, 
and  proceeds  upwards  ;  whereas  the  reverfe  occurs  in 
hernia.  In  hydrocele  the  fpermatic  cord  is  in  mofl: 
inftances  diftindly  felt,  whereas  in  hernia  where  the 
tum.or  defcends  to  the  fcrotum,  the  fpermatic  cord 
cannot  in  any  part  of  its  courfe  be  diftinguifhed.     In 


Sea.  11.  Of  Hernia.  3 

hydrocele,  the  flii£luatioii  of  a  fluid  is  diftlnguifiiable  ; 
in  hernia  it  is  not. 

From  the  anarfarcous  fvvelling  of  the  fcrotum,  or 
hydrocele  of  the  dartos  as  it  is  termed,  hernia  is  eafily 
diftinguillied  ;  and  indeed  the  means  of  diflindion  are 
fo  obvious,  that  they  need  not  be  enumerated  ;  but 
there  is  another  variety  of  hydrocele,  the  hydrocele  of 
the  fpermatic  cord,  which  in  iome  inllances  it  is  diffi-' 
cult  to  diflinguifh  from  hernia,  and  which  therefore 
requires  particular  attention. 

Where  the  water  is  collected  in  one  or  more  cells 
of  the  fpermatic  procefs,  and  begins  in  the  under  part 
of  the  cord,  and  proceeds  upwards,  this  alone  ferves 
as  fufficient  means  of  diftindipn  between  it  and  her- 
nia, in  which  the  fwelling  muft  always  proceed  from 
above  downwards ;  but  it  fometimes  happens,  that 
the  water  begins  to  colled:  even  within  the  opening  of 
the  abdominal  mufcle,  and  by  degrees  falls  down- 
wards. In  this  cafe  we  cannot  determine  from  the 
ftate  of  the  tumor  alone,  whether  it  is  the  one  difeafe 
or  the  other.  The  general  fymptoms  of  hernia,  fuch 
as  pain  and  tenfion  of  the  abdomen,  \T)miting,  and 
obftruded  inteftines,  muil  be  kept  in  view ;  for  not 
being  conneded  with  hydrocele,  they  ferye  to  afcer- 
tain  the  nature  of  the  cafe,  in  which  their  abfence 
might  long  remain  doubtful.  In  fome  cafes,  however, 
thefe  and  everv  other  means  of  diftindlion  are  want- 
ing  ;  but  even  in  fuch  circumftances  a  praditioner  of 
experience  will  never  incur  the  riik  either  of  hurting 
his  patient,  or  his  own  reputation,  which  the  miftak- 
ing  a  hernia  for  a  hydrocele,  and  treating  it  as  fuch, 
muft  always  do,  and  which,  to  the  difgrace  of  furge- 
ry  has  in  fome  inftances  been  done. 

In  all  fuch  cafes  of  doubt,  as  well  as  in  every  tu- 
mor of  the  tefticle  where  the  moft  perfect  certainty  is 
not  obtained,  and  in  which  an  operation  becomes  ne- 
ceflfary,  the  furgeon  (liould  proceed  as  he  would  do  in 
hernia :  by  doing  fo,  every  rifk  will  be  avoided  :  on 
B  2 


4  Of  Hernia*  Chap.  XXIII. 

the  tumor  being  laid  open,  the  true  nature  of  the  dif- 
eafc  will  become  evident,  and  the  practitioner  will  be 
at  liberty  to  apply  the  means  bell  i'uited  for  the  cure. 
Whereas  in  proceeding  differently  as  in  fome  cafes 
has  been  done,  and  treating  as  a  hydrocele  what  after- 
■\vards  proves  to  be  hernia,  he  not  only  incurs  the  ri(k 
of  injuring  his  own  reputation,  but  of  dellroying  his 
patient. 

In  the  treatment  of  the  bubonocele,  when  the  means 
pointed  out  in  the  lafl  fection  as  applicable  to  every 
itate  of  hernia  do  not  fucceed,  we  are  then  under  the 
r.ecefnty  of  proceeding  to  the  operation  ;  and  the  me- 
thod of  doing  it  is  this  : 

A  table  of  a  convenient  height  being  fixed  in  a 
proper  light,  the  patient  mufl  be  placed  upon  it  with 
his  head  and  body  almofl  horizontal,  whilft  his  but- 
tocks are  raifed  with  pillows  beneath  them.  The  legs 
hanging  over  the  edge  of  the  table  muft  be  feparated 
fo  as  to  admit  the  operator  between  them  ;  and  (hould 
in  this  fituation  be  firmly  fecured  by  an  afiiftant  on 
each  fide,  who  fliould  take  care  at  the  fame  time  to 
keep  the  thighs  fo  far  raifed  as  to  relax  the  abdomi- 
nal mufcles. 

That  we.  may  obtain  as  much  empty  fpace  as  poili- 
ble  for  returning  the  protruded  parts,  the  patient 
fhould  be  advifed  to  empty  his  bladder ;  and  the  parts 
having  been  previouily  fhaved,  an  incifion  muft  now 
be  made  with  a  fcalpel  through  the  fkin  and  part  of 
the  cellular  fubftance,  beginning  an  inch  above  the  fu- 
perior  end  of  the  tumor,  and  proceeding  dowH  to  the 
moil  depending  part  of  the  fcrotum.  Even  where  the 
tumor  does  not  reach  to  the  bottom  of  the  fcrotum, 
the  parts  fhould  be  laid  open  in  this  manner.  By  a 
free  external  incifion,  we  are  enabled  to  finifii  the  op- 
eration w^ith  more  eafe  than  when  the  firfl  opening  is 
fmall :  it  does  not  give  much  more  pain ;  and  being 
continued  to  the  bottom  of  the  fcrotum,  the  matter 
in  the  upper  part  of  the  fore  is  prevented  from  col-- 
lecling  below,  which  otherv/ife  it  is  ready  to  do. 


Seel.  II.  Of  Hernia.  5 

The  operator  mufl;  now  proceed  to  divide  the  reft 
of  the  cellular  fubflance  covering  the  fac  ;  and  even 
this  fliould  be  done  with  caution  :  for  although  in  a 
great  proportion  of  cafes,  the  fpcrmatic  veffels  lie  be- 
hind the  protruded  parts,  yet  occafionally  they  are 
found  on  the  anterior  part  of  the  tumor ;  fo  that  in 
order  to  avoid  the  rilk  of  wounding  them,  as  foon  as 
the  ^\m.  is  divided,  the  remainder  of  the  operation 
fliould  be  conduced  with  much  attention,  care  being 
taken  to  avoid  every  large  blood  veflel  that  makes  its 
appearance. 

This  circumftance  of  the  prolapfed  parts  getting 
down  behind  the  fpermatic  veifels,  has  never,  fo  far  as 
I  know,  been  mentioned  by  authors  :  it  mufl  there- 
fore be  a  rare  occurrence.  As  I  met  with  it,  however, 
in  one  cafe,  where  the  fai^l  was  obvious,  the  pofTibility 
of  its  happening  I  have  no  reafon  to  doubt.  If  we  at- 
tend only  to  the  ufual  conformation  of  thefe  parts,  the 
hernial  fac,  we  would  fay,  ought  never  to  get  behind 
the  fpermatic  cord  :  but  we  know  well,  that  in  no  part 
of  the  human  body  is  nature  more  apt  to  defert  her 
ordinary  courfe,  than  in  fome  circumftances  relating 
to  the  teftes  and  their  blood  veffels.  I  have  already 
obferved,  that  till  near  the  period  of  delivery,  the  tef- 
ticles  continue  in  the  abdomen ;  and  about  this  time, 
that  they  fall  down  in  a  gradual  manner  to  the  fci'o- 
tum.  Many  inftances,  however,  occur,  of  both  tefles 
remaining  in  the  abdomen  through  life ;  while  fome- 
times  one  remains,  and  the  other  falls  into  the  fcro- 
tum.  In  others,  one  or  both  fall  into  the  groin,  and 
never  proceed  farther  \  a  circumftance  which  young 
pradlitioners  fliould  be  aware  of,  as  inilances  have  oc- 
curred of  a  teflicle  refling  in  the  groin  being  miflak- 
en  for  a  hernia,  and  of  much  pain  being  excited  by 
attempts  made  for  reducing  them.  Now,  if  we  fre-f 
quently  meet  with  fuch  varieties  as  this  in  the  me-. 
chanifm  of  thefe  parts,  why  may  not  nature  fometimes 
produce  fuch  a  conformation  as,  on  a  hernial  fac  fall- 
ing into  the  fcrotum,  may  place  it  behind  both  the 


6  Of  Hernia.  Chap.  XXIII. 

fpermatic  cord  and  the  teflicle  ?  And  as  I  have  fhewn 
that  it  has  happened,  and  as  it  may  therefore  occur 
again,  I  confider  it  as  a  farther  argument  for  the  proi- 
priety  of  dividing  the  parts  in  the  cautious  manner  I 
have  nientioned.* 

It  is  ufual,  in  making  the  firft  incifion,  to  pinch  up 
the  teguments,  and  then  to  divide  them  with  a  fcal- 
pel ;  but'  no  fui-geon  of  fteadinefs  and  dexterity  will 
ever  proceed  in  this  manner.  This  incifion  of  the  fkin 
is  done  with  much  more  neatnefs,  and  with  equal  fafe- 
ty,  by  the  operator  grafping  the  tumor  with  his  left 
hand,  in  fuch  a  manner  as  to  render  the  teguments  on 
the  anterior  part  of  it  tenfe,  while,  with  the  fcalpel  in 
his  right  hand,  he  divides  the  fkin  from  one  end  to 
the  other. 

The  fac  being  laid  bare,  an  opening  rnufl:  be  made 
in  it,  fo  as  to  bring  its  contents  into  view  ;  and  the 
mofl  fafe  place  for  this  being  formed,  is,  not  about 
the  middle  of  the  tumor,  as  is  commonly  direded,  but 
as  near  to  the  under  point  of  it  as  poffible  :  it  is  here 
done  with  the  fame  eafe  as  in  any  other  part ;  and  be^ 
fides,  the  gut  is  feldom  found  juft  at  the  bottom  of 
the  fac,  which  is  commonly  occupied  with  a  quantity 
of  bloody  ferum  ;  fo  that  the  rifk  of  wounding  it  in 
this  lituation,  is  lefs  than  in  any  other  part  of  the  tu- 
mor. In  making  this  perforation  of  the  fac,  confifts 
the  greatefl  nicety  in  the  operation,  the  utmoft  caution 
being  necelfary  to  avoid  the  parts  which  it  contains. 
Good  eyes  and  a  fteady  hand  are  in  no  operation  more 
requifite  than  in  this  :  with  thefe,  any  practitioner  ac- 
quainted with  the  anatomy  of  the  parts,  will  do  the 
operation  properly,  and  without  them  the  befl  anato- 
mift  mud  go  wrong. 

With  the  fame  fcalpel  that  divided  the  Ikin  and  cel- 
lular fubilance,  the  operator  muft  proceed  {lowly,  di- 


*  since  this  went  to  the  prefs,  I  find  that  an  inftance  is  recorded  by  Le 
Pran,  in  his  TreaOfe  of  Ruptures,  of  the  fpermatic  vefTcls  having  been  found 
on  tlie  anterior  part  of  a  bubonocele.  This  fituation,  therefore,  of  thei't 
vclTcls,  is  perhaps  more  frequent  than  is  conimonly  imagintd. 


Sea.  ir.  Of  Hernia.  y 

viding  one  fibre  of  the  fac  after  another,  till  an  open- 
ing is  formed  in  it ;  which  may  be  always  difcovered 
with  the  blunt  end  of  a  probe  :  if  the  probe  palTes  in 
eafily,  we  may  conclude  with  certainty  that  the  fac  is 
divided  ;  and  if  it  does  not,  the  incifion  mud  be  con- 
tinued in  the  fame  gradual  manner  fomewhat  deeper, 
when  the  fame  trial  with  the  probe  muft  be  repeated. 

In  profecuting  this  divifion  of  the  fac,  we  derive 
much  advantage  from  the  ufe  of  a  fmall  (harp  pointed 
directory,  open  at  the  extremity,  as  is  reprefented  in 
Plate  LXVI.  fig.  3.  By  pufliing  the  end  of  it  below 
fome  of  the  fibres  of  the  fac,  they  are  eafily  feparated 
from  the  parts  beneath,  and  may  thus  be  divided  with 
fafety  ;  and  in  the  fame  manner  the  reft  of  the  fac 
muft  be  divided,  till  this  part  of  the  operation  is  com- 
pleted.* 

In  almoft  every  hernia  in  the  groin,  and  even  where 
the  tumor  extends  to  the  fcrotum,  if  the  parts  are  re- 
cently protruded,  the  hernial  fac  is  thin,  and  therefore 
eafily  cut  through  ;  but  it  is  neceflary  for  the  infor- 
mation of  young  praftitioners,  to  obferve,  that  when 
hernia  is  of  long  duration,  the  fac  frequently  becomes 
fo  thick,  as  to  require  much  more  difledion  than  be- 
ginners commonly  expe6t :  by  going  on,  however, 
with  the  caution  I  have  direded,  every  ri{k  of  wound- 
ing any  part  of  importance  may  be  avoided. 

As  foon  as  an  opening  is  made  through  the  fac,  a 
circumftance  of  which  we  become  certain,  as  I  re- 


*  In  the  4th  volume  of  Memoirs  of  the  Paris  Academy  of  Surgcrv,  there 
is  a  paper  on  Hernia;,  by  Monfieur  Louis.  But  although  it  contains  many 
ufcful  obfervations,  Mr.  Louis  in  one  point  I  think  has  gone  fi.r  wrong,  in 
ridiculing  that  degree  of  cantion  which  in  dividing  the  hernial  fac  is  un- 
queftionably  requifite  :  the  divifion  of  the  fac,  he  fays,  is  attended  with  fo 
little  difficulty,  that  he  does  not  coniidcr  it  as  different  in  that  refpeA  from 
the  firfl  external  incilion  of  the  fkin.  His  words  arc  :  "  Jamais  Ic  fac  ne 
"  m'a  donne  ni  plus  de  peine,  ni  plus  d'cmbarras  que  la  peau  ;  on  divife, 
"  pour  ainfi  dire,  celled  dn  premier  tr.il/,  et  le  fac  du  fecondr  In  tlic  hands 
of  a  very  expert  operator,  the  fcalpcl,  even  in  this  manner,  mav  be  fo 
managed  as  to  do  no  harm  ;  but,  in  common  pradlice,  much  mifcliief  would 
be  done  by  proceeding  as  Mr.  Louis  has  dirc<n:ed.  It  mii^ht  tend  to  lliovv 
the  dexterity  of  an  operator,  but  this  vvoiiJd  always  be  at  the  hazard  of 
the  patient. 


8  Of  Hernia.  Chap.  XXIII. 

marked  above,  by  a  probe  pafiing  eafily  in,  it  ought 
then  to  be  farther  enlarged,  by  cutting  upon  the  di- 
jeclor,  till  it  is  of  fuch  a  fize  as  to  admit  the  forefin- 
ger of  the  operator. 

The  forefinger  of  the  left  hand  mufl:  now  be  intro- 
duced, and  ufed  as  a  director  for  entering  the  narrow 
blunt  pointed  biftoury,  reprefented  in  Plate  LXIV. 
fig.  2.  with  which  the  hernial  fac  mud  be  divided 
along  its  whole  length  up  to  the  opening  in  the  ex- 
ternal oblique  mufcle.  With  the  finger  ufed  as  a  di- 
reQor  for  the  biftoury,  this  part  of  the  operation  is 
performed  with  fafety  ;  and  the  biftoury  here  deline- 
ated, renders  all  the  inftruments  formerly  employed 
not  only  for  this  part  of  the  operation,  but  for  the 
fubfequent  divifion  of  the  tendon,  quite  unneceiTary. 

On  laying  the  fac  open  at  the  bottom,  a  quantity 
of  coloured  fluid  commonly  ruflies  out,  and  the  pro- 
truded parts  come  fully  in  view  :  if  a  portion  of  gut 
is  down,  and  not  much  entangled  with  omentum,  by 
being  nov/  fet  at  liberty,  more  of  it  comes  inftantly  on 
the  fac  being  opened  ;  thereby  giving  the  appearance 
of  having  been  colleflicd  in  a  larger  quantity  than  the 
fize  of  the  tumor  gave  reafon  to  expect. 

The  portion  of  gut  that  we  meet  with  In  hernial 
fwellings  is  various,  no  part  of  the  inteftinal  canal  be- 
ing entirely  exempted  from  falling  dov/n.  Hitherto 
the  ileum  has  been  commonly  fuppofed  to  form  the 
fubftance  of  a  great  proportion  of  hernise,  but  later 
and  more  accurate  obfervation  renders  it  probable  that 
the  c^curn,  appendix  vermiformis,  and  part  of  the 
colon,  are  perhaps  as  frequently  contained  in  hernias 
as  any  other  portion  of  gut. 

The  fac  being  laid  fully  open,  the  parts  contained 
in  it  ftiould  be  examined  with  the  niccft  attention,  in 
order  to  difcover  whether  they  are  found  or  not ;  and 
if  upon  attentive  infpedion  they  appear  to  be  found, 
that  is,  if  they  are  not  evidently  in  a  ft  ate  of  gangrene, 
even  although  they  feem  to  be  inflamed,  they  Ihoulcl 
be  immediately  returned  into  the  abdomen. 


Sea.  II.  Of  Hernia.  9 

Whether  Intefline  or  omentum,  or  a  portion  of 
each,  have  been  contained  in  the  tumor,  thofe  parts 
of  them  which  have  come  laft;  down  fliould  be  firft 
puflicd  back,  the  difficulty  and  trouble  of  returning 
them  being  thereby  much  leffened  :  and  in  making 
the  redudion,  it  both  anfwers  the  purpofe  better,  and 
is  lefs  hkely  to  do  harm,  to  apply  the  lingers  to  that 
part  of  the  intefline  connected  with  the  mel'entery  than 
to  the  convex  part  of  it.  While  the  red ud ion  is  go- 
ing on  the  patient's  thighs  and  loins  fhould  be  (till 
more  elevated  than  they  were  di'»^««ig  the  preceding 
fteps  of  the  operation ;  for  this  pofture  of  thefe  parts 
tends  much  to  facilitate  the  return  of  the  protruded 
inteltines  to  the  abdomen. 

When  the  difeafe  is  recent,  and  the  parts  have  not 
been  frequently  down,  it  fometimes  happens,  that  by 
pulling  out  a  little  more  of  the  gut,  the  difficulty  that 
occurred  to  the  reduction  is  thereby  removed  ;  and  if 
the  protruded  parts  are  not  of  great  magnitude,  they 
may  thus  be  fometimes  reduced,  without  the  opening 
being  enlarged  by  which  they  pafled  from  the  abdo- 
men :  but  when  this  cannot  be  done  with  eafe,  it 
ihould  never  be  attempted  ;  more  danger  being  to  bo 
dreaded  from  force  applied  to  the  gut,  than  can  ever 
occur  from  finiiliing  the  operation  by  enlarging  the 
opening  in  the  tendon  of  the  external  oblique  mufcle. 

As  the  tendon  of  this  mufcle  runs  in  an  oblique  di- 
redlion  from  above  downwards,  and  as  the  opening 
through  which  the  contents  of  a  hernia  protrude,  is 
formed  by  a  feparation  of  the  tendinous  hbres  of  the 
nmfcle  from  each  other,  the  direction  of  this  opcnin>>- 
IS  of  courfe  the  fame  with  that  of  the  tendon  ;  that  is, 
it  runs  fomewhat  obliquely  Irom  the  fpine  of  the  ileum 
to  the  OS  pubis. 

In  enlarging  this  palfagc,  then,  for  the  redu6lion  of 
the  parts  that  have  pafTed  through  it,  as  a  tranfverfe 
fe£tion  of  the  tendon  is  not  neceifary,  the  knife  fhould 
be  carried  obliquely  upwards,  fo  as  merely  to  conti- 
nue the  natural  feparatipn  of  the  tendinous  fibres. 


10  Of  Henna.  Chap.  XXIII. 

The  finger  was  recommended  as  the  beft  director 
for  the  knife  in  opening  the  fac,  and  in  dividing  the 
tendon  it  proves  equally  ufeful.  By  infmuating  the 
finger  into  the  aperture  of  the  tendon  immediately 
above  the  protruded  parts,  the  point  of  the  blunt  bif- 
toury,  Plate  LXIV.  fig.  2.  is  eafily  introduced  upon 
it ;  and  in  this  manner,  by  keeping  the  end  of  the  fin- 
ger a  little  before  the  biftoury,  the  opening  may  be 
enlarged  to  any  neceifary  extent  without  rifls.  of  wound- 
ing the  contiguous  parts. 

In  general,  a  ve^-y  fmall  enlargement  of  the  natural 
opening  in  the  tendon  proves  fufficient :  but  the  fize 
cf  the  opening  ftiould  be  fully  equal  to  the  objeft  in 
view  ;  for  it  is  better  to  make  it  fomev/hat  too  large, 
than  to  run  any  riili  of  hurting  the  gut  by  forcing  it 
through  a  fmail  aperture. 

If  on  the  introduction  of  the  finger  any  adhefions 
of  the  gut  to  the  contiguous  parts  are  difcovered,  the 
incifion  in  the  tendon  fhould  be  made  lar;][er  than  might 
otherwife  be  neceifary,  that  the  finger  may  be  fo  free- 
ly admitted,  as  to  dellroy  fuch  adhefions  as  it  can 
reach  ;  for  if  not  removed,  the  operation  would  very 
probably  fail. 

Befides  thefc  internal  adhefions,  it  fometimes  hap- 
pens, by  long  confinement  in  the  fcrotum  ;  preifure  ; 
and  perhaps  from  other  caufes  ;  that  flirong  adhefions 
are  formed  among  the  parts  contained  in  the  fac  :  and 
before  reducing  them,  it  is  ahvays  right  to  attempt  to 
feparate  them. 

"When  thefe  adhefions  occur,  as  they  fometimes  do, 
between  different  parts  of  the  gut,  they  fhould  be  fep- 
arated  with  much  care  ;  but  connedions  of  this  kind 
between  one  portion  of  gut  and  another,  are  feldom 
firm,  and  are  commonly  eafily  feparated  :  when  form- 
ed by  means  of  long  filaments,  which  is  fometimes  the 
cafe,  the  eafiefl  method  of  removing  them  is  to  cut 
them,  either  with  fciffars  or  a  biiloury  ;  but  when  one 
part  of  the  gut  adheres  fo  firmly  to  another,  as  not  to 
be  feparated  but  with  difficulty,  it  is  much  better  to 


Sea.  II.  Of  Hcrn'KX.  1 1 

return  the  whole  even  in  this  (late  to  the  abdomen, 
than  to  run  the  rill;,  of  hurting  it  by  employing  much 
force. 

When,  again,  adhefions  form  between  the  gut  and 
the  hernial  fac,  or  between  the  gut  and  omentum,  if 
the  filaments  by  which  they  are  produced  cannot  be 
otherwife  removed,  as  there  is  no  great  hazard  in 
wounding  the  omentum,  and  flill  Itfs  trom  hurling 
the  fac,  a  fmall  portioh  of  both  may  be  diffeded  oR, 
;and  returned  with  the  gut  to  the  abdomen  ;  and  in  like 
manner,  when  the  omentum  adheres  fo  firmly  to  the 
iac  as  not  to  be  feparated  in  any  mother  manner,  no  dan- 
ger can  accrue  from  the  fac  being  encroached  on. 

The  rilk  attending  this  pradlice  is  trifling,  when 
.compared  with  the  inconveniencies  that  would  enfuc 
from  leaving  either  the  omentum  or  gut  adhering  ex- 
ternally to  the  hernial  fac,  as  is  advifed  by  fome  when 
thefe  adhefions  cannot  be  eafily  divided.  The  lead 
portion  of  gut  being  left  down,  would  run  much  rifk 
of  being  injured  by  expofure  at  the  different  dreflings  ; 
and  by  leaving  part  of  the  omentum  to  protrude 
through  the  opening  from  the  abdomen,  one  advan- 
tage to  be  expected  from  the  operation  would  be  loft, 
namely,  the  prevention  in  future  of  that  rifle  to  v/hich 
a  patient  with  a  portion  of  protruded  omentum  mufl 
be  always  liable,  of  a  piece  of  gut  flipping  down,  and 
perhaps  of  becoming  ftrangulated. 

After  returning  the  contents  of  the  fac  into  the  ab- 
domen, it  has  been  propofed  by  fome,  to  pafs  a  liga- 
ture round  the  upper  part  of  the  fac  jufl  at  its  neck, 
with  a  view,  as  we  are  told,  of  procuring  a  reunion  of 
its  fides,  in  order  that  it  may  ferve  as  a  means  of  pre- 
venting future  defcents  of  the  bowels. 

But  as  a  hgature  cannot  be  applied  in  this  manner 
without  rifl-i  of  injuring,  or  even  of  deflroying  the  fper- 
matic  vefTels,  with  which  the  poflerior  part  of  the  fac 
is  immediately  connected,  the  practice,  from  this  con- 
fideration  alone,  fhould  be  laid  afide  ;  but  in  reality  it 
docs  not  appear  to  be  neceflfary,  as  this  very  union  of 


11  Of  Hernia.  Chap.  XXIII. 

the  fides  of  the  fac  is  always  produced  merely  by  that 
degree  of  inflammation  which  fucceeds  to  the  opera- 
tion. 

Hitherto  I  have  advifed  the  contents  of  hernias  to 
be  immediately  reduced,  on  the  fuppofition  that  they 
have  been  only  diiplaced  ;  that  they  have  been  ad- 
hering to  each  other  or  to  the  neighbouring  parts  ;  or 
perhaps  that  they  have  been  more  or  lefs  in  a  ftate  of 
inflammation.  But  when  it  appears  that  this  inflam- 
mation has  already  ended  in  gangrene,  as  the  return 
of  mortified  parts,  whether  omentum  or  intefl:ine, 
might  be  attended  v/ith  hazard,  more  caution  is  re- 
quired. 

When  the  omentum  is  found  in  a  ftate  of  mortifi- 
cation, as  a  portion  of  it  may  be  removed  without 
much  rifl;,  it  has  been  the  common  pradice  to  cut  off 
the  difcafed  parts  ;  and  in  order  to  obviate  any  incon- 
venience from  the  hemorrhagy  that  might  enfue,  we 
are  advifed  to  make  a  ligature  on  the  found  parts  pre- 
vious to  the  removal  of  thofe  that  are  mortified  j  while, 
by  leaving  the  ends  of  the  ligature  hanging  out  of  the 
wound,  the  furgeon  has  it  in  his  power  to  remove  it 
whenever  he  may  think  fit. 

Ligatures  on  the  omentum,  however,  having  fre- 
quently induced  bad  fymptoms,  fuch  as  naufea,  vomit- 
ing, cough,  fevef,  pains  in  the  belly,  and  inability  to 
fit  erect ;  and  as  we  now  from  experience  know,  that 
no  hemorrhagy  of  importance  ever  occurs  from  its 
being  divided,  fuch  parts  as  have  become  gangrenous 
mav  therefore  be  freely  cut  ofl',  and  the  remaining 
found  parts  be  introduced  into  the  abdomen,  without 
ligatures  being  put  upon  them.  Of  this  I  am  con- 
vinced from  expei'ience,  and  it  is  alfo  the  opinion  of 
others  :*  but  if  it  fliould  ever  happen,  on  cutting  oiT 
part  of  the  omentum,  that  a  vefl^el  of  any  fize  is  dir 

*  A  very  accurate  paper  upon  this  fiibje<5l  may  be  feen  in  the  third 
volume  of  Mcmoircs  de  i'Academie  Royalc  de  CJhirurgie  of  Paris,  by  Mon-: 
f)tiu-  Piyiekt,  in  which  frveral  >.-.i'es  arc  relati^d  of  the  bad  cffcdls  product 
cd  by  Jigitiirts  on  the  omentum. 

Mr.  Poit  is  alfo  of  this  opinion.     Vide  Trcatife  on  Ruptures. 


Sea.  II.  Of  Hernia,  13 

vided,  a  ligature  may  with  fafety  be  pafled  upon  it 
with  the  tenaculum,  without  including  any  part  of  the 
membrane ;.  and  the  ends  of  it  being  left  to  hang  out 
at  the  wound,  it  may  afterwards  be  pulled  away  at 
pleafure. 

Another  circumflance  fometimes  occurs,  that  ren- 
ders the  removal  of  part  of  the  omentum  neceflary  : 
when  a  henia  has  been  of  long  duration,  and  a  por- 
tion of  omentum  has  been  long  down,  from  the  pref- 
fure  made  by  the  ufual  fufpenfory  bandage,  the  pro- 
truded parts  are  apt  to  become  thickened,  hard,  and 
collected  :nto  lumps.  When  thefe  lumps  are  not 
large,  ther  need  not  be  removed,  and  when  fmall, 
they  may  be  returned  into  the  abdomen  without  haz- 
ard ;  but  ivhenever  it  appears,  that  by  their  bulk  and 
hardnefs  they  might  do  mifchief  if  forced  into  the 
belly,  they  ought  certainly  to  be  cut  off. 

When  ve  determine  to  remove  any  part  of  the 
omentum,  the  eafieft  and  fafeft  method  of  doing  it  is 
this.  The  membrane  fliould  be  carefully  expanded 
at  the  part  intended  to  be  cut,  in  which  fhate  it  is  ea- 
fily  divided  with  thin  edged  fciflars,  more  fo  indeed 
than  with  any  other  inftrument.  When  fully  fpread 
out,  any  turn  of  the  intelline  that  may  be  enveloped 
in  it,  is  at  once  brought  to  view,  which,  without  this 
precaution,  v/e  would  run  the  rilk  of  dividing  with 
the  fciffars. 

"When,  sgain,  a  portion  of  gut  is  found  to  be  mor- 
tified, if  returned  in  this  (late,  a  difcharge  of  feces 
would  certainly  take  place  into  the  cavity  of  the  ab- 
domen, as  foon  as  the  mortified  fpot  lliould  feparate 
from  the  found.  For  the  prevention  of  this,  which 
would  foor.  terminate  in  the  death  of  the  patient,  if  a 
finall  fpot  only  is  difeafed,  we  fhould  endeavour,  with 
a  needle  and  ligature,  to  conned  the  found  part  of 
the  gut  immediately  above  the  mortified  fpot,  to  the 
wound  in  the  abdominal  mufcles.  By  this  the  feces 
are  difchai'ged  by  the  wound,  when  the  mortified  fpot 
either  feparates  or  is  cut  out  5  and  different  inftances 


14  Of  Hernia.  Chap.  XXIir. 

have  occurred,  where  the  lofs  of  fubftance  produced 
by  the  mortification  was  not  extenfive,  of  the  openinp- 
into  the  gut  becoming  gradually  lefs,  and  at  lait  heal- 
ing entirely :  but  whether  the  event  {hould  prove  fo 
fortunate  or  not,  whenever  a  portion  of  gut  is  com- 
pletely mortified,  it  fhould  be  fecured  with  a  ligature 
to  the  contiguous  parts. 

And  farther,  when  the  mortification  is  extenfive, 
and  includes,  fo  far  as  it  goes-,  the  whole  circumfer- 
ence of  the  gut,  the  gangrenous  parts  fhould  be  cut 
out  at  once ;  and  if  the  quantity  thus  taken  away  is 
not  fo  confiderable  as  to  prevent  the  ends  of  the  gut 
from  being  brought  into  contac):,  it  fhould  be  done 
immediately  in  the  manner  pointed  out  in  Chapter  III, 
Sedion  XII.  when  treatiDjT  of  wounds  of  :he  intefli- 

o 

nal  canal :  this  at  leafl  affords  a  chance  o:'  the  ends 
of  the  gut  being  made  to  reunite  ;  and  if  this  unluck- 
ily fhould  not  happen,  a  paffage  for  the  feces  will  flill 
be  fecured  by  the  groin. 

Although  in  this  manner  many  have  recovered  who 
otherwife  mufl  have  died ;  3^et  it  mufl  be  admitted, 
that  the  rifk  of  patients  in  this  fituation  is  very  con- 
fiderable :  but  although  a  fmall  proportion  only 
fliould  recover,  ftill  praftitioners  would  be  to  blame 
were  they  to  omit  thofe  means  which  afFcrd  the  beft 
chance  to  their  patients.  A  patient  of  my  own  is  now 
living,  and  in  good  health,  voiding  his  feces  by  the 
anus,  who  loft:  at  leafl  one  foot  of  the  inteftinal  canal 
by  mortification  in  a  cafe  of  crural  hernii ;  and  we 
are  told  by  different  authors,  of  fimilar  recoveries 
equally  remarkable. 

It  is  to  the  moderns  chiefly,  I  may  remark,  that  we 
owe  this  important  improvement  in  the  treatment  of 
hernia.  It  is  even  recorded  of  Rau,  whc  lived  in  a 
very  late  period,  that  on  opening  a  hernial  fac,  where 
a  gangrenous  flate  of  the  parts  was  difcovered,  as  the 
cafe  was  fuppofed  to  be  defperate,  he  laid  down  his 
knife,  and  proceeded  no  farther  in  the  operation. 


Sea.  II.  Of  Hcm'ia.  15 

The  patient,  who  died  next  day,  would,  in  modern 
praftice,  have  had  at  leaft  feme  chance  for  life. 

When  it  is  therefore  difcovered,  that  mortification 
has  taken  place,  all  the  dileafed  parts  fliould  be  cut 
off,  and  the  remaining  found  part  of  the  gut  being 
retained  with  the  fingers  till  properly  fccured  with  a 
ligature,  the  opening  in  the  external  oblique  mufclc 
may  then  be  dilated  with  fafety  :  whereas,  if  it  fhould 
be  enlarged  before  the  difeafed  part  of  the  gut  is  tak- 
en away,  the  gangrenous  portion  might  flip  up  togeth- 
er with  the  found  ;  but  by  this  precaution,  every  rilk 
of  this  kind  is  avoided. 

The  parts  forming  a  hernia  being  all  completely 
replaced,  when  the  fac  in  which  they  were  contained 
is  found  to  be  hard,  enlarged,  and  much  thickened, 
as  no  advantage  could  be  derived  from  prcferving  it, 
fuch  pai-ts  of  it  as  can  be  cut  away  with  fafety  fhould 
be  removed :  all  the  lateral  and  foreparts  of  the  fac 
may  be  fafely  cut  off;  but  being  commonly  firmly 
connefted  with  the  fpermatic  veffels  behind,  this  part- 
of  it  ought  not  to  be  touched. 

In  common  practice,  the  parts  are  now  dreffed  with 
foft  lint,  and  a  fufpenfory  bag  employed  for  retaining 
it.  But  it  anfwers  better  to  draw  the  fides  of  the  cut 
previoufly  together,  including  the  llun,  cellular  fub- 
ftance,  and  anterior  part  of  the  hernial  fac,  with  a 
proper  number  of  futures,  by  which  the  cure  is  much 
more  quickly  accomplilhed,  at  the  fame  time  that  the 
parts  are  rendered  more  firm  than  they  otherwife 
would  be  :  at  one  time,  this  pra£lice  appeared  to  me 
to  be  hazardous  ;  and  I  advifed  it  not  to  be  adopted, 
as  in  tVv'o  inftances  a  portion  of  gut  got  down  between 
the  futures,  and  one  of  the  patients  died  before  it  was 
perceived :  farther  experience,  however,  has  made  it 
obvious,  that  this  may  be  always  prevented,  and  that 
in  various  v/ays  it  proves  ufeful :  when  the  futures 
are  not  above  half  an  inch  from  each  other,  and  made 
to  pafs  to  the  bottom  of  the  fore,  fo  as  to  include  all 
the  anterior  part  of  the  fac,  this  accident  can  never 


1 6  Of  Hernia,  Chap.  XXIIL 

happen.  With  a  view  to  give  a  free  vent  to  any  matter 
that  may  form  in  the  courfe  of  the  cut,  I  have,  in 
fome  inftances,  left  an  opening  at  the  under  part  of 
it,  but  this  precaution  I  now  beheve  to  be  unnecefTa- 
ry  :  the  futures  being  completed,  the  parts  fliould  be 
all  covered  with  a  pledget  of  any  emollient  ointment, 
together  with  fome  plies  of  foft  lint,  and  the  whole 
retained  by  the  T  bandage. 

The  patient  muil  now  be  carried  to  bed ;  and  be- 
ing fo  placed  as  to  have  his  loins  fomewhat  elevated 
above  the  reft  of  his  body,  he  fhould  in  this  fituation 
be  laid  to  reft :  opiates  are  here  particularly  ufeful  : 
to  prevent,  or  at  leaft  to  moderate,  the  fever  which 
commonly  facceeds,  the  patient  ftiould  be  kept  cool : 
in  plethoric  habits,  bloodletting  fliould  be  prefcribed, 
together  with  a  rigid  low  diet ;  and,  lailly,  if  the  bel- 
ly is  not  naturally  open,  a  frequent  ufe  of  gentle  lax- 
atives is  particularly  proper. 

When,  however,  the  ftrength  has  been  previoufly 
much  reduced,  either  by  long  ficknefs  or  any  other 
caufe,  inftead  of  bloodletting  and  a  low  diet,  a  nour- 
ifliing  regimen  becomes  neceifary  ;  for  if  a  patient  in 
fuch  circumftances  is  not  properly  fupported,  he  will 
not  fo  readily  recover :  it  is  alfo  proper  to  remark, 
that,  in  common  praftice,  the  indifcriminate  ufe  of 
bl(K:)dletting,  and  an  abftemious  regimen,  in  eveiy 
cafe  of  hei-nia,  appears  to  be  too  rigidly  adhered  to  j 
for,  althoufijh  it  proves  alv/ays  ufeful  in  hernia,  attend- 
ed with  inflammation,  yet  daily  experience  makes  it 
obvious,  that  it  proves  hurtful  where  the  fyftem  has 
been  already  much  reduced  by  evacuations,  and  where 
no  inflammatory  fymptoms  take  place. 

The  fore  ftiould  be  looked  at  and  drcfted  daily,  by 
tvhich  means  any  change  that  may  take  place  in  it 
will  be  quickly  dll'covered  :  the  ligatures  in  the  courfe 
of  fix  or  feven  days  fhould  be  withdrawn,  and  as  foon 
as  the  parts  are  firmly  cicatrized,  a  well  adapted  trufs 
fhould  be  applied  to  them,  and  never  afterwards  laid 
afide :  fome  indeed  aiTert,  that  a  trufs  after  this  oper- 


Sea.  11.  Of  Hernia.  17 

ation  is  unnecefTary,  and  where  the  cure  has  been  ac- 
compllfhed  with  ligatures  deeply  placed,  in  the  man- 
ner I  have  pointed  out,  it  might  in  fome  inftances  be 
fo  complete,  particularly  during  youth,  as  to  prevent 
all  future  defcents ;  but  as  the  contrary  has,  in  vari- 
ous inftances,  happened,  the  patient  fhould  be  always 
put  on  his  guard  againft  it. 

In  performing  this  operation,  it  was  propofed  a 
confiderable  time  ago  by  Mr.  Petit,  of  Paris,  and  oth- 
er French  pra6litioners,  to  reduce  the  protruded  parts, 
without  dividing  the  fac  :  fince  that  period,  the  prac- 
tice has  been  adopted  by  others.  Dr.  Monro  thinks 
favourably  of  it,  and  on  his  fuggeftion  I  have,  in  dif- 
ferent cafes,  performed  the  operation  in  this  manner. 
But,  however  unwilling  I  am  to  differ  from  fuch  au- 
thority, I  cannot  in  this  inftance  avoid  it :  the  chief 
reafon' affigned  for  not  opening  the  fac,  is,  that  we 
thereby  prevent  the  air  from  finding  accefs  to  the  in- 
teftines ;  but  although  this  would  be  highly  defirablcj 
if  the  operation  could  otherwife  be  equally  well  per- 
formed, as  it  does  not  appear  to  me  that  this  can  be 
done,  I  think  it  right  to  obferve,  that  the  pra£lice 
fhould  be  received  with  caution,  till,  by  further  obfer- 
vation,  it  is  afcertaincd,  whether  it  proves  beneficial 
or  not.  The  bcft  mode  of  doing  it  would  be  for  the 
furgeons  of  thofe  hofpitals  in  which  hernioe  moft  fre- 
quently occur,  to  perform  the  operation  a  confidera- 
ble number  of  times  in  each  method,  and  to  judge 
from  the  refult,  for  we  fhould  not  decide  upon  a  point 
of  fuch  importance  on  the  experience  to  be  obtained 
from  a  few  cafes. 

The  chief  objection  to  the  pradice  is,  that  unlefs 
the  hernial  fac  is  laid  open,  we  cannot  poflibly  diftin- 
guifli  the  ftate  in  which  the  parts  contained  in  it  are ; 
fo  that  parts  might  be  returned  into  the  abdomen  in 
fuch  a  ftate  of  difeafe  as  would  add  greatly  to  the  haz- 
ard of  the  patient.  The  inteftines  are  not  only  liable 
to  mortifv,  but  colleflions  are  fometiraes  found  in  the 

Vol.  III.  C 


i8  Of  Hernia.  Chap.  XXIIL 

hernial  fee,  of  a  fetid  putrid  ferum,  which,  on  being 
pufhed  into  the  abdomen,  might  do  much  harm.  And 
befides,  it  has  fometimcs  happened,  on  laying  open  a 
hernial  fac,  that  the  caufe  of  ftrangulation  has  been: 
difcovered,  either  in  the  fac  itfelf,  or  among  the  parts 
contained  in  it :  for  although,  in  a  great  proportion 
of  cafes,  a  flriclure  of  the  paflage  through  which  the 
parts  have  come  down,  is  to  be  confidered  as  the 
caufe  of  all  the  bad  fymptoms,  yet  inftances  of  the 
contrary  fometimes  occur ;  one  of  which  I  met  with 
fome  years  ago,  and  I  have  heard  of  others  of  the 
fame  kind.  In  a  cafe  of  fcrctal  hernia  of  long  dura- 
tion, fymptoms  of  ftrangulation  at  laft  fupervened ; 
and  on  laying  open  the  fac,  the  appendix  vermiformis 
was  found  fo  tightly  twifted  round  a  portion  of  gut, 
as  left  no  reafon  to  doubt  of  this  alone  being  the  caufe 
of  the  mifchief.  If  the  parts  had  here  been  returned 
without  dividing  the  fac,  no  advantage  would  have 
been  derived  from  the  operation ;  and,  after  death, 
the  practitioner  would  have  had  the  mortification  to 
find,  that  the  patient's  Hfe  might  have  been  faved,  if 
this  very  neceffary  meafure  had  not  been  omitted. 

Inftances  of  the  protruded  parts  being  returned  in- 
to the  abdomen  without  opening  the  fac,  are  enume- 
rated by  different  French  practitioners  ;  and  in  fome 
which  ended  fatally,  it  was  found  on  diiTection,  that 
the  ftrangulation  of  the  gut  had  been  the  effeft  of 
ftriClure  formed  by  the  parts  contained  within  the  fac, 
and  not  by  the  tendon  of  the  external  oblique  muf- 
cles  through  which  they  had  palTed. 

Difafters  of  a  fimilar  nature  having  occurred  to  Mr» 
Petit  and  others,  who  had  adopted  the  pradice,  it  has 
long  in  France  been  very  generally  laid  afide ;  but  in 
a  point  of  fuch  importanccj^this  will  not  be  univerfal- 
iy  done  till  further  experience  fliall  evince  whether  it 
ought  to  be  continued  or  not. 

By  fome  again,  we  are  advifed  to  reduce  not  only 
the  protruded  bowels,  but  even  the  hernial  fac  itielf ; 
whiift  others  allege,  that  the  fac  can  never  be  reduc- 


Seia.  It.  Of  Hernia.,  19 

ed.  Mr.  Louis,  in  the  paper  I  have  quoted,  is  clearly 
of  this  laft  opinon,  as  Mr.  Pott  alfo  is.  But  we  have 
the  teftimony  of  different  authors  of  credit,  and  par- 
ticularly of  Mr.  Le  Dran,  to  the  contrary  ;  and  I  have 
now  met  with  it  in  more  than  one  inftance,  where  the 
appearances  were  fo  unequivocal  as  to  leave  no  doubt 
with  me  refpedling  it. 

In  hernial  of  long  duration,  where  the  parts  have 
been  long  and  repeatedly  down,  fuch  firm  adhefions 
ufually  form  between  the  fac  and  the  contiguous 
parts,  as  to  reduce  them  apparently  into  one  infepara- 
blc  mafs  ;  fo  that,  in  fuch  circumftances,  all  attempts 
to  reduce  the  fac  would  be  in  vain.  But  although 
this  would  perhaps  in  every  inftance  be  the  cafe  in 
ruptures  of  long  continuance,  we  are  not  warranted 
in  fuppofmg  that  it  would  be  fo  in  every  cafe  of  re- 
cent hernia.  We  know  that  the  adhefion  of  one  part 
of  the  body  to  another,  cannot  any  where  be  inftan- 
taneoufly  produced.  Even  where  recent  divifion  has 
taken  place,  and  when  the  divided  parts  are  kept  in 
clofe  contaft,  the  fpace  of  feme  days  is  commonly  re- 
quired to  produce  a  firm  reunion.  Now  in  the  cafe 
of  a  portion  of  membrane  being  forced  into  a  natural 
opening,  where  the  parts  are  neither  rendered  raw  by 
art,  nor  are  as  yet  in  a  flate  of  inflammation,  a  ftill 
longer  period  mufl  be  required  for  this  effeft  ;  and  in 
fad,  although  there  is  fcarcely  perhaps  an  inftance  of 
a  hernial  fac  of  long  duration  being  reduced,  yet  there 
are  fundry  indifputable  fads  which  fhow,  that  in  re- 
cent ruptures  it  may  be  returned.  In  one  of  thofe  to 
which  I  allude,  the  gut  had  been  down  five  or  fix 
days,  and  formed  a  tumor  in  the  groin  of  the  fize  of 
an  egg  :  the  fac  did  not  in  any  point  feem  to  adhere ; 
the  operator  therefore  found  no  difficulty  in  reducing 
it ;  and  on  difledion  after  death,  which  happened  in 
two  days  from  the  operation,  the  pafTage  through  the 
External  oblique  mufcle  was  found  dilated,  but  no  ex- 
iltence  of  a  fac  could  be  traced  into  it.  This  alfo 
c  2 


20  Of  Hernia,  Chap.  XXIIL- 

was  the  cafe  with  the  other,  which  had  been  down 
for  tweh'e  or  thirteen  days.  It  is  not,  however,  my 
own  opinion,  that  this  is  a  matter  of  much  practical 
importance,  I  mean  the  poillbility  of  reducing  the  her- 
nial fac  or  not ;  for  the  reafons  I  have  enumerated 
againfl  the  return  of  a  hernia  without  opening  the 
fac,  occur  with  equal  force  againfl  our  returning  the 
fac  itfelf  unopened. 

The  obfervations  that  I  have  hitherto  made  relate 
chiefly  to  hernia  in  the  male  fubjed  ;  but  as  the  fame 
openings  in  the  external  oblique  mufcles  exift  in  fe- 
males, fo  they  are  alfo  liable  to  the  variety  of  rupture 
we  have  iull  been  defcribine. 

In  males,  however,  the  bubonocele  is  more  fre- 
quentdy  met  with  than  in  women,  and  as  in  them  too 
the  cellular  membrane  furrounding  the  fpermatic  vef- 
fels  is  very  lax  and  dilatable,  fo  hernial  fwellings  of 
this  part  are  commonly  much  larger  in  them  than  in 
women.  But  inftances  fometimes  occur,  even  in  wo- 
men, of  the  bubonocele  being  of  great  bulk  :  I  have 
known  the  protruded  parts  fall  down  to  the  very  bot- 
tom of  the  labia  pudendi. 

As  the  openings  in  the  external  oblique  mufcles  of 
females  ai*e  exceedingly  fimilar  to  thofe  in  the  male, 
fo  the  treatment,  of  bubonocele  is  in  them  very  fimi- 
lar to  v.'hat  is  found  to  anfwer  in  men.  When  glyf- 
ters,  bloodletting,  and  the  other  remedies  enumerated 
above  do  not  fucceed,  the  fame  operation  of  laying 
open  the  hernial  fac,  and  enlarging  the  opening  in  the 
tendon  of  the  oblique  mufcle,  is  here  equally  proper 
as  in  the  other  fex. 

With  modefl  women,  hernias  often  take  place  with-- 
out  the  praditioner  in  attendance  being  made  acquaint- 
ed v/ith  them  ;  whenever  tlierefore  fuch  fymptoms  of 
cholic  occur  in  females  as  give  reafon  to  fufpect  the 
exiftence  of  hernia,  a  particular  examination  fhould 
always  be  made,  in  order  if  pofTible  to  difcover  the 
caufe  of  the  mifchief,  from  the  removal  of  which  alone 
a  cure  can  be  obtained. 


Seel.  III.  Of  Hernia,  2 1 

In  this  manner,  I  have,  in  different  inftances,  faved 
the  lives  of  patients,  who  otherwife  in  all  probability 
would  have  died,  without  the  caufe  of  their  difeafe  be- 
ing known :  with  fome  women  this  would  happen 
from  delicacy  alone  ;  .but  inftances  alfo  occur,  of  her- 
nias ending  fatally,  where  the  tumors  are  fo  fmall  as 
fcarcely  to  attradt  attention  even  from  the  patient. 


SECTION     III. 
Of  the  Hernia  Congenita. 


FROM  the  anatomical  defcription  given  in  the  firft 
fedion  of  this  chapter,  of  the  parts  chiefly  con- 
cerned in  hernia,  it  appears,  that  in  the  common  her- 
nia of  the  fcrotum,  the  parts  protruded  from  the  ab- 
domen muft  necefi'arily  be  contained  in  a  bag  or  fac 
perfedlly  diflin£t  from  the  teftis  :  in  that  kind  of  rup- 
ture, the  teftis  therefore  remains  in  its  ufual  fituation, 
furrounded  by  its  own  proper  membrane  the  tunica 
vaginalis,  and  not  in  contad  with  any  other  part. 

But  from  the  fame  defcription  it  appears,  that  if  in 
early  infancy  a  portion  of  gut  fhould  flip  down  by  the 
fame  paflTage  with  the  teilicle,  that  the  parts  ip  pro- 
truded muft  be  in  immediate  contaft  with  the  teftis, 
and  muft  thus  be  contained  in  the  tunica  vaginalis  ; 
fo  that  in  this  rupture,  very  properly  by  Haller  term- 
ed hernia  congenita,  the  tunica  vaginalis  teftis  forms 
the  hernial  fac. 

The  difcovery  of  this  variety  of  hernia,  which  was 
referved  for  modern  times,  enables  us  to  account  for 
a  number  of  cafes  recorded  in  books  of  furgery,  of 
the  contents  of  ruptures  being  found  in  the  fame  bag 
with  the  tefticle  ;  a  circumftance  which,  till  this  dif- 
covery, was  confidered  as  a  clear  proof  of  the  perito- 
naeum being  frequently  ruptured  in  hernia,  as  till  of 
late  this  phenomenon  could  not  otkerwife  be  explain^ 


22  Of  Herma.  Chap.  XXIII. 

ed.  But  we  now  know,  that  the  peritonaeum  is  never 
ruptured  in  hernia  ;  and  that  the  parts  forming  a  her- 
nial tumor  being  found  in  contact  with  the  teflicle,  is 
a  circumflance  eafily  explained  from  the  more  accu- 
rate knowledge  we  have  obtained  of  thefe  parts. 

The  treatment  of  the  congenital  hernia  fhould  be 
nearly  the  fame  with  that  of  bubonocele  in  its  more 
ordinary  form.  When  the  parts  can  be  replaced 
without  an  operation,  it  ought  always  to  be  done,  a 
trufs  being  at  the  fame  time  recommended  as  a  pre- 
ventive of  future  jiefcents ;  and  when  fymptoms  of 
of  ftrangulalion  take  place,  which  cannot  be  other- 
wife  removed,  than  by  the  operation,  it  here  becomes 
equally  proper  as  in  the  common  form  of  the  difeafe. 

When  from  a  hernia  having  taken  place  in  early 
infancy,  and  from  the  parts  having  continued  to  fall 
into  the  fcrotum  occafionally  from  that  period  down- 
wards, there  is  reafon  to  fufpedt  that  a  rupture  in 
which  llrangulation  has  taken  place  is  of  the  congeni- 
tal kind,  the  furgeon,  in  dividing  the  fac,  fhould  pro- 
ceed with  ftill  more  caution  than  in  common  hernia  j 
for  the  tunica  vaginalis  which  here  forms  the  fac,  is 
commonly  much  thinner  than  the  ufual  fac  of  a  her- 
nia. On  the  parts  being  returned,  more  attention  is 
•alfo  necelTary  in  dreffing  the  wound  than  in  other  ca- 
fes of  rupture ;  for  the  teflicle  being  here  laid  bare 
by  the  vaginal  coat  being  cut  open,  if  not  treated  with 
much  delicacy  it  might  probably  inflame,  and  be 
thereby  the  caufe  of  much  additional  diflrefs  and  dan- 
ger. The  teflis  therefore  fhould  be  immediately  en- 
veloped with  its  own  proper  covering,  the  loofe  tuni- 
ca vaginalis ;  aind  every  drefTmg  fhould  be  fo  conduct- 
ed as  to  prevent  with  as  much  certainty  as  pofTible  the 
external  air  from  finding  accefs. 

In  other  circumflances  the  management  of  the  her- 
nia congenita  is  the  lame  with  that  of  any  oth^^r  rup- 
ture. 


Sea.  IV.  Of  Hernia.  23 

SFXTION     IV. 
Of  the  Crural  or  Femoral  Hernia. 

THE  feat  of  the  crural  hernia,  as  I  have  remarked 
above,  is  on  the  upper  and  anterior  part  of  the 
thigh ;  the  protruded  parts  pafling  out  at  the  fame 
opening  through  which  the  large  blood  veffels  of  the 
thigh  are  transmitted  from  the  abdomen. 

In  the  defcription  given  in  the  firft  fedion  of  this 
Chapter,  of  the  external  obhque  mufcles  of  the  abdo- 
men, I  remarked,  that  the  under  edge  of  thefe  muf- 
cles, by  doubling  backwards,  affumes  the  appearance 
of  a  ligament,  extending  in  an  oblique  diredion  from 
the  fpine  of  the  ileum  near  to  the  fymphyfis  pubis, 
and  forming  what  is  commonly  termed  the  ligament 
of  Poupart  or  Fallopius. 

Excepting  at  its  two  extremities,  where  this  liga- 
ment is  attached  to  the  pubes  and  ileum,  it  is  not  in 
any  other  part  connedted  with  bone.  By  the  particu- 
lar fliape  of  the  ileum  at  this  part,  a  kind  of  arch  is 
formed,  by  the  ligament  pafling  over  a  hollow  in  that 
bone,  through  which  the  large  artery  and  veins  of  the 
thigh  find  a  palTage,  the  rell  of  the  cavity  being  filled 
up  with  cellular  fubftance,  glands,  and  fiit ;  and  all 
thefe  parts  again  are  covered  with  and  tied  down  by 
a  firm  tendinous  aponeurofis  of  the  fafcia  lata  of  the 
thigh. 

It  is  under  the  tendon  or  ligament  juft  now  defcribed, 
that  the  parts  compofnig  a  crural  hernia  defccnd.  In 
fome  inftances  they  pafs  immediately  over  the  femo- 
ral artery  and  vein  ;  in  others,  they  are  found  on  the 
outfide  of  thefe  veflels  ;  but  more  frequently  they  lie 
on  the  infide,  between  them  and  the  os  pubis. 

As  the  protrufion  and  ftrangulation  of  any  of  the 
contents  of  the  abdomen,  excites  nearly  the  fame 
fymptoms,  wherever  this  difeafe  takes  place  j  fo  the 


24  Of  Hernia,  Chap.  XXIII. 

fymptoms  of  crural  hernia  are  fo  fimilar  to  thofe  def- 
cribed  in  the  two  firfl  fedions  of  this  Chapter,  that 
it  is  not  necelTary  to  mention  them  here. 

The  cure  of  the  femoral  hernia  is  alfo  conducted 
upon  the  fame  principles  with  that  of  bubonocele,  de- 
fcribed  in  the  fecond  feftion  ;  fo  that  when  fymptoms 
of  llrangulation  take  place  in  it,  the  farne  remedies 
fhould  be  employed  that  were  advifed  above  for  bu- 
bonocele. Only  here,  in  attempting  to  reduce  the 
parts  by  the  hand,  the  preiTure  fhould  be  made  di- 
reftly  upwards,  inftead  of  obliquely  outwards,  as  was 
advifed  in  the  other  ;  and  when  thefe  means  do  not 
fucceed,  the  operation  itfelf  muft  be  employed. 

In  defcribing  the  operation  for  the  inguinal  hernia, 
I  advifed  the  external  incifion  to  be  free  and  exten* 
five.  It  is  ftill  more  neceflary  in  the  crural  hernia, 
from  the  parts  concerned  in  it  being  more  deeply 
feated.  By  timidity  in  making  the  firil  incifion,  the 
operator  is  frequently  much  incommoded  in  all  the 
fubfequent  parts  of  the  operation.  The  external  cut 
Ihould  extend  at  leafl  from  an  inch  above  the  upper 
end  of  the  tumor  to  the  fame  length  below  the  mofl 
depending  part  of  it. 

The  membrana  adipofa,  tendinous  expanfion  of  the 
fafcia  lata,  and  hernial  fac,  being  all  divided,  if  the 
protruded  parts  are  found  in  a  fit  flate  for  redudion, 
we  fhould  immediately  attempt  to  replace  them  ;  and 
as  the  fpace  below  the  ligament  through  which  they 
have  paflfed  is  confiderable,  this  may  commonly  be 
done  without  dividing  it,  merely  by  prefTure  properly 
applied  with  the  fingers,  while  the  patient  is  placed  in 
the  pofture  directed  above  for  the  operation  of  the  bu- 
bonocele as  being  befl  fuited  for  favouring  a  return 
of  the  bowels. 

When  the  contents  of  the  tumor  can  be  reduced 
without  dividing  the  ligament,  the  patient  is  thereby 
faved  from  a  good  deal  of  hazard,  as  from  the  fitua- 
tion  of  the  fpermatic  veffels  ^nd  epigaflric  artery  with 


(Sea.  IV.  Of  l-lcrnicz.  25 

refpect  to  this  ligament,  any  cut  made  into  it  is  done 
Tifith  the  rifk  of  thefe  veffels  being  injured. 

The  fpermatic  veffels  in  pafling  along  towards  the 
opening  in  the  external  oblique  mufcle,  run  nearly 
upon  the  very  edge  or  border  of  Poupart's  ligament, 
fo  that  I  confider  it  as  impoffible  to  make  a  free  di- 
yifion  of  the  ligament  without  cutting  tlieui  acrofs. 

We  have  been  advifed  indeed  by  fome,  in  order  to 
avoid  the  fpermatic  veffels,  which  they  allow  would 
be  wounded,  if  the  incifion  fliould  be  carried  directly 
upwards,  to  cut  in  an  oblique  dircftion  outwards. 
They  admit,  that  in  this  way  the  epigaftric  artery  may 
probably  be  divided ;  but  the  rilk  attending  the  divi- 
fion  of  that  artery  they  do  not  confider  as  of  much 
importance ;  and  if  the  difcharge  of  blood  which  it 
might  produce  Ihould  happen  to  be  confiderable,  they 
fpeak  of  it  as  an  eafy  matter  to  take  it  up  with  a  liga- 
ture ;  for  which  purpofe  needles  of  various  fliapes 
have  been  invented.  Even  in  emaciated  people, 
however,  it  is  difficult  to  reach  the  epigaftric  artery 
with  a  ligature,  and  in  corpulent  patients  it  muft  of- 
ten be  impoffible ;  fo  that  the  younger  part  of  the 
profellion  fliould  be  cautious  in  receiving  the  direc- 
tions ufually  given  on  this  point.  On  reading  the  re- 
marks of  the  late  Mr.  Sharpe  on  it,*  to  fecure  the  epi- 
gaftric artery  with  a  Hgature,  one  would  expect  to  be 
the  eafieft  of  all  operations  ;  but  the  dirficulty  which 
attends  it,  is  fuch,  as  muft  convince  all  who  have  tri- 
ed it,  that  Mr.  Sharpe  himfelf  never  put  it  in  prac- 
tice. 

But  even  although  the  epigaftric  artery  could  with 
certainty  be  avoided,  if  a  hernia  is  large,  the  ligament 
is  fo  much  ftretched  as  to  bring  the  fpermatic  veflels 
fo  nearly  on  a  line  with  the  under  edge  of  it,  as  to 
render  it  altogether  impoffible  to  divide  the  one  with- 
out the  other  ;  and  whoever  will  examine  thefe  parts 
in  this  fituation,  will  fee  that  this  cannot  be  avoided, 

*  Critical  Inquiry  into  the  prcfent  ftate  of  Surgery. 


a6  Of  Hernia.  Chap.  XXIII. 

■whether  the  incifion  is  carried  direiStly  upwards,  or 
obliquely  outwards  or  inwards. 

Some  who  have  been  fenfible  of  the  danger  attend- 
ing this  part  of  the  operation,  have  propofed  merely 
to  dilate  the  pafllige  inflead  of  dividing  the  ligament ; 
and  Mr.  Arnaud,  a  French  author,  delineates  a  curv- 
ed levator  for  the  purpofe  of  fupporting  the  ligament 
till  the  protruded  parts  are  reduced  :  but  as  we  are  to 
fuppofe  in  evei-y  cafe  of  flrangulated  hernia,  that  the 
palfage  through  which  the  parts  have  fallen  down  is 
already  dilated  to  nearly  its  utmoft  polTible  extent,  in 
fiich  a  fituation  to  attempt  a  farther  dilatation,  without 
the  afliitance  of  the  knife,  would  feldom,  it  is  proba- 
ble anfwer  any  good  purpofe. 

A  confiv^erable  time  ago  it  occurred  to  me,  that  in 
this  part  of  the  operation  fome  alfiftance  might  be  de- 
rived from  performing  it  in  the  follovdng  manner ; 
and  having  fince  had  occaiion  to  put  it  in  praftice 
with  fuccefs,  I  can  now  V\1th  fome  confidence  recom- 
mend it.  Inftead  of  dividing  the  ligament  in  the  or- 
dinaiT  way,  from  below  upwards,  I  make  a  flight  in- 
cifion into  it,  about  an  inch  in  length,  beginning  above 
and  proceeding  to  the  under  edge  of  it. 

The  firfl  fcratch  with  the  fcalpel  fhould  be  flight ; 
but  by  repeated  touches,  it  fliould  be  made  to  pene- 
trate almoffc  through  the  whole  thicknefs  of  the  liga- 
ment, till  at  lafr  only  a  thin  layer  of  it  remains :  in 
this  fituation  the  protruded  parts  may  for  the  molt 
part  be  returned  with  eafe,  as  the  ligament  where  thus 
weakened  by  the  incifion  will  yield  gradually  to  the 
prcffure  applied  for  the  reduction  of  the  iiiteifines. 

As  in  this  manner  the  opening  may  be  enlarged  to 
any  necefiary  extent,  and  as  the  fpermatic  veffels  and 
epigaftric  artery  are  thus  avoided,  the  operation  may 
not  only  be  done  with  equal  certainty,  but  with  the 
fame  fafety,  as  for  any  other  rupture.  For,  by  not 
penetrating  with  the  fcalpel  through  the  whole  thick- 
nefs of  the  lig:\mcnt  under  which  thcfe  blood  veiftls 
lie,  they  are  thereby  kept  free  from  danger  during 


Soft.  V.  Of  Hernia.  27 

tliis  part  of  the  operation  ;  and  the  preffure  afterwnrJs 
ufcd  for  the  redudion  of  the  protruded  parts,  if  done 
in  a  gradual  manner,  can  never  injure  them  material- 
ly, as  blood  veffels  of  the  fize  and  ftrength  of  thefe 
e'afily  admit  of  much  more  extenfion  than  is  here  re- 
quired. 

In  every  other  circumflance,  the  crural  hernia,  as  I 
have  obferv^ed  already,  requires  the  fame  method  of 
treatment  with  bubonocele,  for  Vv'hich  the  fecond  Sec- 
tion of  this  Chapter  may  be  confulted  :  only  I  may 
remark,  that  the  dreflings  are  more  eafily  retained  af- 
ter this  operation,  by  a  piece  of  leather  fpread  with  plaf- 
ter  moderately  adhefive,  than  with  any  kind  of  band- 
age. 

I  have  already  obferved,  that  the  crural  hernia  is 
more  frequent  in  women  than  in  men,  owing  to  the 
particular  conformation  of  the  parts  in  which  it  oc- 
curs. In  women  the  fame  mode  of  operating  fliould 
be  obferved  as  in  men ;  for  as  in  them  there  is  the 
fame  rifk  of  wounding  the  epigaftric  artery,  the  fame 
precautions  are  neceffary  for  avoiding  it,  and  by  at- 
tending to  the  diredions  given  above,  it  may  be  al- 
ways done. 


SECTION     V. 

Of  the  Exomphalos,  or  U/nbilical  Rupture. 

IN  this  variety  of  hernia,  the  parts  protruded  from 
the  abdomen  pal's  out  at  the  umbilicus  ;  and  the 
contents  of  the  hernial  fac  are  here,  as  in  every  other 
rupture,  exceedingly  various.  In  fome  inftances  they 
confifl  of  inteflines  only  ;  fometimes  of  omentum  on- 
ly ;  and  frequently  of  both.  In  fome,  part  of  the  fto- 
mach,  liver,  and  fpleen,  have  been  found  in  the  fac  of 
an  umbilical  rupture. 


88  Of  Hernia,  Chap.  XXIIL 

As  all  thefe  parts  are  naturally  contained  in  the  pe- 
Htonceum,  the  hernial  fac,  it  is  evident,  mud  here  as  in 
other  ruptures  be  formed  by  that  membrane  being 
carried  along  with  fuch  parts  as  are  protruded.  Ac- 
cordingly, in  every  recent  inftance  of  umbilical  her- 
nia, this  fac  is  in  general  evident ;  but  when  the  tu- 
mor is  large,  the  fac  becomes  fo  intimately  connedted 
with  the  contiguous  parts,  in  confequence  of  the 
weight  and  preffure  of  its  contents,  that  many  have 
doubted  whether  this  fpecies  of  hernia  has  a  fac  or 
not.  In  fome  inftances  the  tumor  has  increafed  to 
fuch  a  degree,  as  actually  to  burJl  the  furrounding 
parts ;  not  only  the  fac,  and  cellular  fubitance,  but 
even  the  fkin  itfeif. 

Umbilical  hernise  occur  moft  frequently  in  early 
infancy,  and  in  corpulent  people  more  frequently  than 
in  others,  from  this  obvious  reafon,  that  by  the  great 
bulk  of  parts  contained  in  the  abdomen  of  fat  people, 
the  furrounding  mufcles  are  kept  conftantly  diftend- 
ed,  by  which  the  opening  at  the  umbilicus,  through 
which  the  parts  are  protruded,  is  made  more  pervi- 
ous :  for  a  fimilar  reafon,  women  in  the  lafl  months 
of  pregnancy  are  particularly  liable  to  this  rupture. 

If  attended  to  in  due  time,  a  right  bandage  will 
commonly  efTccb  a  cure ;  and,  when  produced  by 
pregnancy,  a  temporary  removal  of  the  difeafe,  is,  in 
general,  a  certain  confequence  of  delivery.  "While  a 
woman  continues  pregnant,  we  can  feldom  remove  an 
umbilical  rupture,  but  by  employing  a  bandage  early 
we  can  in  this  fituation  prevent  the  tumor  from  be- 
coming larger. 

Although  different  portions  of  the  aliamentary  czl- 
nal  are  occafionally  met  with  in  umbilical  ruptures ; 
yet  by  experience  we  know,  that  mod:  frequently  they 
contain  omentum  only :  hence  umbilical  herniee  are 
not  in  general  fo  hazardous  as  other  ruptures. 

It  happens,  however,  as  I  have  obferved  above,  that 
in  fome  cafes  a  portion  of  gut  alone  is  puflied  out,  by 
which  the  ufuai  fymptoms  of  ftrangulaticn  are  apt  to 


Sea.  V.  Of  Hernia,  29 

be  induced.  In  this  fituation,  when  the  means  ufual-' 
ly  employed  for  returning  the  gut  do  not  fucceed,  as 
a  ftrifture  of  the  pafTage  through  which  it  has  fallen, 
is  to  be  confidered  as  the  fole  caufe  of  the  danger  ;  fo 
a  cure,  it  is  evident,  mud  depend  entirely  on  this  be- 
ing removed.  In  performing  this  operation,  a  free 
external  incifion  along  the  courfe  of  the  tumor  is  the 
firft  ftep  to  be  taken ;  and  on  laying  the  protruded 
parts  bare  by  a  cautious  divifion  of  the  fac,  if  they  are 
found  in  a  ftate  fit  to  be  returned,  and  if  this  cannot 
be  effeded  but  by  enlarging  the  paflage  into  the  ab- 
domen, it  may  be  done  with  fafety  by  introducing  the 
fmger,  and  enlarging  the  opening  with  a  blunt  point- 
ed biftouiy.  This  incifion,  I  may  remark,  may  be 
made  with  almoft  equal  fafety  in  any  direftion ;  but 
left  the  ligament  formed  by  the  umbilical  veifels  fhould 
be  wounded,  which,  however,  would  not  probably  do 
much  harm,  yet  when  an  operator  is  of  a  different 
opinion,  it  may  always  be  avoided  by  making  the  cut 
on  the  left  fide  of  the  umbilicus,  and  carr}^iiig  it  a 
little  obliquely  upwards  and  outwards. 

When,  again,  the  prolapfed  parts,  on  being  laid 
open,  are  found  to  be  fo  much  difeafed  as  to  render 
their  reduftion  improper,  the  diredtions  formerly  giv- 
en for  fimilar  occurrences  in  other  cafes  of  hernia, 
will  apply  with  equal  propriety  here,  and  need  not 
now  be  repeated. 

By  Albucafis,  Guido,  Aquapendens,  and  others,  it 
has  been  propofed,  with  a  view  to  obtain  a  radical 
cure  without  the  operation,  to  lift  up  the  fkin  cover- 
ing the  tumor,  with  the  finger  and  thumb,  fo  as  to 
feparate  it  from  the  gut  beneath  ;  and  a  cord  being 
pafled  round  the  parts  thus  raifed  up,  a  ligature  to  be 
made  fo  tight  as  to  induce  mortification  over  the  whole 
of  them. 

In  other  inftances  again,  when  the  form  of  the 
fwelling  did  not  admit  of  this,  the  fame  precaution  be- 
ing taken  for  avoiding  the  gut,  a  needle  containing  a 
double  ligature  was  introduced  through  the  bafis  of 


30  Of  Hernia.  Chap.  XXIH/ 

the  tumor,  near  to  its  centre,  and  the  ligatures  afrer- 
wards  tied  one  above  and  the  other  below,  of  fuch 
tightnefs  as  to  induce  the  wifiied  for  effect. 

But  as  the  pratlice  thus  recommended  did  not  an- 
fwcr  the  purpofe,  for  it  did  not  prevent  a  return  of 
the  difeafe,  and  as  the  deilrudlion  of  fkin  rendered 
every  future  defcent  more  dangerous,  fo  it  is  now,  at 
leaf):  by  regular  praditioners,  very  univerfally  ex- 
ploded. 

In  Plate  LXV.  fig.  3.  is  reprefented  the  befl  ban- 
dage I  have  ufed  for  umbilical  heniiss. 


SECTION  VJ. 

Of  Ventral  Hernia. 


IN  ventral  hernia  the  parts  forming  the  tumor  arc' 
protruded  between  the  interflices  of  the  abdominal 
mufcles.  No  part  of  the  abdomen  is  altogether  ex- 
empted from  thefe  tumors,  but  they  are  moll  frequent 
in  the  parts  mofl  contiguous  to  the  linea  alba  ;  and 
when  the  flomach  alone  forms  the  tumor,  the  fwell-" 
ing  is  fituated  juft  under,  or  immediately  to  one  fide  of 
the  xiphoid  cartilage. 

The  treatment  of  this  rupture  correfponds  with  that' 
of  exomphalos.  When  the  parts  are  reducible  by  the 
hand  alone,  a  cure  may  be  frequently  obtained  by  the 
conflant  ufe  of  a  trufs  ;  and,  again,  when  fymptoms 
of  (trangulation  occur,  which  cannot  be  removed  but 
by  an  incifion  through  the  ftricture,  this  muft  be  done 
in  the  m?.nner  pointed  out  in  the  laft  feftion,  fo  as  to 
admit  of  the  parts  being  replaced.  The  after  treat- 
ment of  the  parts  concerned  in  the  operation,  is  the 
fame  here  as  in  the  umbilical  rupture. 


Sea.  VII.  Of  Hernia.  3t 

SECTION     VII. 

Of  the  Hernia  of  the  Foramen  Ovale. 

IN  this  rupture,  the  vifcera  protrude  through  the  fo- 
ramen ovale  of  the  pubis  and  ifchium.  It  is  not 
a  frequent  variety  of  the  difcafe  ;  but  as  it  has  been 
met  with,  it  is  neceflary  to  defcribe  it. 

The  fymptoms  of  this  hernia  being  very  fimilar  to 
thofe  arifing  from  ftrangulated  inteftines  in  other  parts, 
they  need  not  be  enumerated  here  :  only  it  is  proper 
to  remark,  that  in  this  rupture  the  tumor  is  in  men 
formed  near  to  the  upper  part  of  the  perina;um  ;  and 
in  women,  near  to  the  under  part  of  one  of  the  labia 
pudendi.  In  both  fexes  it  lies  upon  the  obturator  ex- 
ternus,  between  the  peclineus  mufcle  and  the  firfl  head 
of  the  triceps  femoris. 

The  foramen  ovale  being  partly  filled  up  by  a  mem- 
branous or  ligamentous  fubltance,  and  in  part  by  the 
obturatores  mufcles,  it  was  commonly  fuppofed  that 
this  fpecies  of  hernia  arofe  from  a  relaxation  of  one  or 
other  of  thefe  ;  but  as  an  opening  is  left  in  the  fora- 
men for  the  tranfmiilion  of  different  blood  vell'els  and 
nerves,  it  is  now  known,  that  in  this  rupture  the  vif- 
cera pafs  out  at  that  opening,  by  gliding  down  in  the 
courfe  of  thefe  vefl'els. 

The  general  mode  of  treatment  pointed  out  in  the 
preceding  fedlions  for  other  hernia!,  muft  be  here  kept 
in  view  ;  and  when  the  parts  are  reduced,  a  trufs  pro- 
perly adapted  to  the  parts,  muft  be  trufted  to  for  re- 
taining them.  But,  as  it  will  fometimes  happen  in 
this,  as  in  every  other  hernia,  that  the  parts  cannot  be 
reduced  with  the  Hand  alone,  when  this  is  found  to 
be  the  cafe,  it  muft  be  done  by  dilating  the  pafTage 
through  which  they  protrude.  The  tumor,  however, 
that  takes  place  here,  being  in  general  fo  fmall  as 
fcarcely  to  be  noticed  but  by  the  mod  minute  atten- 


32  Of  Herma.       ^    Chap.  tXIlL 

tlon,  unlefs  a  local  pain,  \\i\h  the  ufual  fymptoms  of 
a  ftrangulatcd  gut  happen  to  lead  to  it,  it  is  feldoui 
difcovered  from  its  fize,  till  it  is  too  late  to  expedt 
much  affiilance  from  art. 

But  whenever  the  operation  becomes  neceffary,  as 
it  mufl  always  be  when  fymptoms  of  flrangulation 
arife  from  a  portion  of  protruded  gut  that  cannot  by 
any  other  means  be  reduced,  after  carefully  laying  the 
prolapfed  parts  bare,  if  they  cannot  be  reduced  but 
by  dilating  ihe  pafiage,  and  as  death  mufl  enfue  ire- 
duction  canhot  be  accompliflied,  it  ought  undoubted- 
ly to  be  attempted  :  but  as  it  is  almofl  impoflible  to 
enlarge  this  opening  with  an  inflrument,  without  di-^ 
viding  fome  of  the  blood  veffels  that  pafs  out  at  the 
foramen  ;  and  as  this  would  probably  end  in  the  death' 
of  the  patient,  the  depth  and  fituation  of  the  parts' 
rendering  the  application  of  a  ligature  impracticable ; 
it  is  more  advil'able,  by  means  of  a  flat  hook,  to  dilate 
the  paflage  to  a  fufficient  fize,  by  gentle  gradual 
ftretchingv  By  infmuating  the  end  of  the  hook  be- 
tween the  inteftine  and  ligament,  and  pulling  it  gra- 
dually upwards,  a  degree  of  dilatation  may  be  obtain- 
ed, fufficient  for  the  reduftion  of  the  gut,  without  in- 
curring that  hazardAvhich  the  divifion  of  the  ligament 
with  the  knife  or  any  fharp  inftrument  mud  always 
occafion.  A  hook  for  this  purpofe  is  delineated  in- 
Plate  LXVr.  fig.  2. 


SECTION     VIII. 

Of  the  Hernia  C-^fica^  or  Hernia  of  the  Urinary 

Bladder. 

N  this  rupture,  the  urinary  bladder  is  the  organ 
protruded  ;  and  the  fituations  in  which  it  occurs, 
are  either  the  groin  and  fcrotum  through  the  opening 
in  the  external  oblique  mufcle  of  the  abdomen  j  the 


.Sea.  VIII.  Of  Hcrni<z,  33 

forepart  of  the  thigh  under  Poupart's  ligament ;  or 
the  perinaeum  through  fome  of  the  mufcular  mter- 
ftices  of  that  part.*  Inftances  have  likewife  happen- 
ed, of  the  bladder  being  pufhcd  into  the  vagina,  lb  as 
to  form  hernial  tumors  of  confidcrablc  bulk. 

As  only  a  part  of  the  bladder  is  covered  with  the 
peritonaeum  ;  and  as  the  bladder,  in  order  to  get  into 
the  opening  in  the  external  oblique  mufcle,  or  under 
the  ligament  of  Fallopius,  muft  infmuate  itfelf  be- 
tween that  membrane  and  the  abdominal  mufcles,  it 
is  evident,  that  the  hernia  cvRica  cannot  be  covered 
with  a  fac,  as  inteitinal  ruptures  ufually  are.  In  the 
perina:um,  again,  that  portion  of  the  bladder  mofl: 
liable  to  fall  into  it,  is  in  no  way  conncfted  with  the 
peritonaeum.  • 

In  fome  inftances;  this  rupture  occurs  by  itfelf, 
without  any  complication  ;  and  in  others  it  is  accom- 
panied with  inteliines  and  omentum,  both  in  inguinal 
and  femoral  hernijE  :  when  comphcated  with  a  bubo- 
nocele, the  protruded  portion  of  the  bladder  lies  be- 
tween the  hernial  fac  and  fpermatic  cord  j  that  is,  the 
inteftinal  hernia  lies  anterior  to  it. 

The  ufual  fymptoms  of  this  hernia  are,  a  tumor, 
attended  with  fluctuation,  either  in  the  groin,  in  the 
forepart  of  the  thigh,  or  perinasum,  which  gradually 
fubfides  when  the  patient  voids  urine,  and  becomes 
larger  when  the  bladder  is  full.  When  the  tumor  is 
large,  before  v/ater  can  be  paiTed  with  freedom,  it  is 
commonly  neceffary  to  employ  preffure,  at  the  fame 
time  that,  when  in  the  groin  or  thigh,  the  parts  re- 
quire to  be  as  much  elevated  as  poffible  ;  but  when 
the  tumor  is  fmall,  and  efpecially  when  no  ftrifturs 
has  taken  place,  the  patient  generally  voids  urine  eafi- 
ly,  and  without  afliflance  from  external  prefiure. 

When  a  hernia  of  thd  bladder  takes  place  without 
any  complication,  it  commonly  proceeds  from  a  fup- 

•  An  inftance  of  this  is  recorded  in  vol.  iv.  of  Mcmoircs  de  I'Acadeinie 
Rovale  dc  Cliirurglc,  by  Mons.  Pipt'lct  Ic  Jcunc,  p.  iSi.  *■ 

VoL.JII.  D 


34  Of  I-Icrnicc.  Chap.  XXIII. 

preflion  of  urine.  In  the  method  of  cure,  there- 
fore, every  caufe  of  fuppreffion  Ihould,  as  far  as  pof- 
fible,  be  guarded  againlt  ;  and  if  the  protruded  por- 
tion of  bladder  can  be  reduced,  a  trufs  properly  fitted 
to  the  part,  fhould  be  worn  for  a  confiderable  time. 
But  when  the  parts  cannot  be  reduced,  as  long  as  no 
fymptoms  appear  to  render  the  operation  neceflary,  a 
fufpenfory  bag,  fo  fitted  as  effect ually  to  fupport  the 
tumor  without  comprefling  it,  is  perhaps  the  only  re- 
medy we  fhould  employ. 

When,  again,  a  portion  of  bladder  protrudes  into 
the  vagina,  after  reducing  the  parts,  which  we  do  by 
laying  the  patient  on  her  back,  with  her  loins  eleva- 
ted, and  preffing  with  the  fingers  from  the  vagina,  de- 
fcentS  in  future  may,  in  general,  be  prevented  by  the 
ufe  of  the  pefTary  reprefented  in  Plate  LXVI.  fig.  i. 
And  the  fame  means,  I  may  remark,  are  employed 
with  fuccefs,  in  preventing  defcents  of  the  inteftinal 
canal  into  the  vagina  j  a  fpecies  of  rupture  fometimes 
met  with. 

It  may  happen,  however,  if  inflammation  occurs 
here,  that  the  divifion  of  the  parts  producing  the  flric- 
ture  will  be  as  neceffar)-  as  in  any  other  rupture.  In 
which  event,  the  mode  of  operating  pointed  out  in  the 
preceding  feftions  fhould  be  kept  in  view.  Only  it 
muft  be  remembered,  that  as  in  the  hernia  cyflica 
vvithou-t  any  complication,  the  protruded  parts  are  not 
covered  with  a  fac,  fo  ftill  more  caution  is  required  in 
laying  them  bare,  than  is  neceflary  in  common  rup- 
tures. 

It  fometimes  happens,  that  ftones  are  produced  in 
the  protruded  portion  of  the  bladder.  In  which  event, 
if  it  ihould  ever  be  necelfary  to  cut  into  them,  if  the 
bladder  can  be  eafily  retained  In  its  prolapfed  flate  till 
the  wound  is  healed,  it  ought  always  to  be  done,  in 
order  to  prevent  that  internal  extravafatlon  of  urine 
which  otherwife  would  occur,  and  which  certainly 
WQukl  do  harm.     The  fame  precaution  is  neceifary. 


Sed.  VIII.  Of  Hernia.  35 

when  by  accident  in  the  operation  for  the  hernia  cyf- 
tica,  the  bladder  is  opened  ;  or  when  any  part  of  it  is 
in  a  ftate  of  mortification,  and  therefore  unfit  to  be 
returned  into  the  abdomen.* 


•  The  bcfl  accounts  of  all  the  varieties  of  hernia  are  to  be  met  with  in 
the  works  of  Le  Dran,  Heiftcr,  and  of  Maiichart,  in  a  Treatife  de  Hernia 
Incarcerata  ;  in  the  diflerent  volumes  of  Memoirts  dc  I'Acadcmie  Rovalc 
de  Chirurgie  dc  Paris  ;  in  the  Medical  HiTays  of  Edinburgh  ;  in  the  works 
of  the  late  Dr.  Monro;  in  Hdller  de  Hernia  Congenita,  in  his  Opufcula 
Patholoj^ica ;  in  Mr.  John  Hunter's  very  accurate  account  cif  the  flate  of 
the  teftis  in  the  foetus,  to  be  met  with  in  Dr.  Hunter's  Medical  Commen- 
taries ;  in  Mr.  Pott's  and  Dr.  Richter's  valuable  works  on  this  fubjecl. 
Thefe  are  the  befl  modern  authors  on  this  fubjeiit;  and  very  little  fatis* 
faction  is  to  be  obtained  from  any  of  the  ancient  writers  upou  iu 


D  2 


,36  On  the  Hydrocele.        Chap.  XXIV. 


CHAPTER     XXIV. 

ON  THE  HYDROCELE. 


SECTION    I. 

General  Remarks  on  the  Hydrocele. 

EVERY  tumor  formed  by  a  colle6lion  of  water, 
may,  from  the  import  of  the  word,  be  called  a 
hydrocele,  but,  in  chirurgical  language,  the  term  im- 
plies a  v/atery  fwelling  in  the  fcrotum  or  fpermatic 
cord. 

This,  as  well  as  all  tumors  in  the  fcrotum  or  groin, 
not  immediately  produced  by  the  protrufion  of  parts 
from  the  abdomen,  were,  by  ancient  writers,  termed 
falfe  or  fpurious  hernise,  from  the  refemblance  which 
they  bear  to  the  true  hernia,  or  rupture ;  but  no  ad- 
vantage is  derived  from  this  diftindion :  and,  as  it 
arofe  from  an  erroneous  opinion  of  the  origin  of  her- 
niae,  I  fhould  not  have  taken  notice  of  it  here,  but 
with  the  view  of  making  the  writings  of  the  ancients 
upon  this  fubject  intelligible. 

Indeed,  the  doclrines  of  the  writers  of  the  lall  and 
preceding  centuries  concerning  hydrocele,  are  fo  con- 
fufed  and  perplexed,  that  they  do  not  merit  attention  j 
for,  as  they  were  ignorant  of  the  anatomy  of  the  parts 
in  which  the  difeafe  is  feated,  the  ideas  which  they 
formed  of  it,  gave  rife  both  to  an  erroneous  patholo- 
gy and  pernicious  practice.  Not  being  acquainted 
with  the  ilru6ture  of  the  parts  aflected,  they  proceed- 
ed with  much  unneceffary  dread  in  the  treatment  of 
the  difeafes  to  which  they  were  liable ;  for,  by  fup- 
pofing  an  immediate  connection  to  fubfift  between  the 
-coats  of  the  teHide,  the  cavity  of  the  abdomen,  liver. 


Sed:.  L  On  the  Hydrocele,  37 

kidneys,  and  other  vifcera,  they  were  induced  to  con- 
fider  the  colleftion  of  water  in  hydrocele,  as  a  depo- 
fition  from  thefe  parts,  and  as  tending  to  free  them, 
and  perhaps  the  fyftem  at  large,  from  difeafes  of  im- 
portance. 

In  confequence  of  this,  their  prav}:ice  was  timid  and 
indecifive ;  fo  that  eveiy  chirurgical  operation,  in 
which  thefe  parts  were  concerned,  became  a  matter 
of  much  importance  to  refolve  upon,  and  very  tedi- 
ous, painful,  and  uncertain  in  the  execution. 

From  the  time  of  Ceh'us  to  the  middle  of  the  lad 
century,  little  progrefs  fcems  to  have  been  made  in 
this  part  of  chirurgical  pathology.  Indeed,  from  Cel- 
fus  downwards,  authors  feem  to  have  copied  almoll 
exaftly  from  one  another,  till  Wifeman,  Le  Dran, 
Garangeot,  and  Heifter,  gradually  elucidated  the  fub- 
jeft  :  but  it  was  not  clearly  underdood  till  the  dif- 
coveries  of  Monro,  Haller,  Hunter  and  Pott,  made 
the  anatomy  of  the  parts  plain  and  intelligible.  So 
much  attention,  however,  is  ftill  given  to  the  confuf- 
ed  accounts  of  ancient  writers,  that  the  real  nature  of 
the  difeafes  of  the  teftes,  and  their  appendages,  is, 
from  this  caufe  alone,  lefs  underflood  than  it  other- 
wife  would  be.  There  is  perhaps  no  part  indeed  of 
furgery  with  which  Undents  in  general  are  fo  little  ac- 
quainted. 

Nothing  but  a  ftrid  attention  to  the  difcoveries  of 
late  anatomifts,  can  convey  clear  and  diftind  ideas 
concerning  them  ;  and,  whoever  will  make  hlmfelf 
acquainted  with  thefe,  will  iind,  that  the  hydrocele 
and  affedions  of  the  teftes,  may  be  explained  with  as 
much  clearnefs  and  funplicity  as  any  other  clafs  of 
difeafes.  In  the  lirft  Section  of  Chapter  XXIII.  I 
gave  a  defcription  of  thef(?  parts,  in  fo  far  as  was  ne- 
ceflary  for  the  confideration  of  hernia.  Referring  to 
what  I  had  then  occafion  to  fay,  commencing  in  page 
527,  and  ending  page  533,  Vol.  II.  I  have  now  only  to 
add  what  may  be  necellary  for  underftanding  more 
completely  the  difeafes  of  the  teftes,  and  their  tunics, 


38  On  the  Hydrocele.  Chap.  XXIV. 

As  from  the  forefaid  defcription  It  appears,  that  the 
teflis  while  in  the  abdomen  is  firmly  attached  to  the 
peritonaeum  behind,  fo,  when  in  the  fcrotum,  as  the 
vaginal  coat  with  which  it  is  there  furrounded,  is  evi- 
dently a  continuation  of  the  peritoncEum,  it  mud  of 
neceffity  be  ftill  connected  with  that  membrane,  in  the 
fame  manner  as  while  it  remained  in  the  abdomen. 
And  accordingly  we  find,  that,  although  the  tefliclc 
lies  loofe  in  this  fac,  or  vaginal  coat,  in  every  other 
part ;  yet,  along  its  poflerior  part,  it  is  firmly  attached 
to  it.  At  this  part,  the  different  veffels  of  the  teftis 
ftill  enter ;  and  at  this  the  peritonaeum,  or  what  is 
now  the  tunica  vaginalis,  is  reflefted  over  it,  and  eve- 
ry where  clofely  attached  to  it,  thereby  forniing  the 
tunica  albuginea,  or  immediate  covering  of  the  tefti- 
cle ;  fo  that  the  tunica  albuginea  is  demonflrably  a 
mere  continuation  of  the  other,  or  vaginal  coat. 

The  inferior  part  of  this  procefs  of  the  peritoneum 
being  fomewhat  wider  below  than  above,  leaves  the 
tunica  vaginalis  of  a  pyramidal  form ;  and  it  is  alfo 
fomewhat  longer  than  the  teflis,  reaching  from  the 
fuperior  part  of  the  epididymis,  where  it  begins,  to  a 
little  below  the  inferior  point  of  the  teflicle,  where  it 
terminates.  It  is  altogether  of  fuch  a  fize  as  to  allow 
the  teflis  to  roll  eafily  within  it ;  its  principal  ufe  ap- 
pearing to  be,  to  retain  a  fmall  quantity  of  a  fine  ex- 
halation, which  is  conflantly  fecreting,  either  from  its 
own  furface,  or  from  the  furface  of  the  tefl:is  itfelf,  for 
the  purpofe  of  keeping  the  latter  moifl  and  eafy. 

The  vaginal  coat,  of  which  I  have  thus  given  a  de- 
fcription, is  the  only  loofe  covering  belonging  either 
to  the  fpermatic  cord  or  teftis  :  for  although,  by  ma- 
ny, a  vaginal  coat  of  the  fpermatic  cord  is  alfo  de- 
fcribed,  together  with  a  fuppofed  feptum  between  it 
and  the  vaginal  coat  of  the  teflis,  yet  no  fuch  cover- 
ing is,  on  diffeclion,  found  to  exift.  The  upper  part 
of  what  may  be  called  the  fpermatic  procefs  of  the 
peritonaeum,  is  evidently  clofed,  as  has  been  defcribed 
above,  foon  after  the  defcent  of  the  teflicle  y  and  a 


Se£t.  I.  0)1  the  Hydrocele.  39 

firm  adhefion  taking  place  between  the  cord  and  that 
part  of  the  fac  with  which  it  is  enveloped,  no  veftige 
can  be  traced,  either  of  a  vaginal  coat  of  the  fperma- 
tic  cord,  or  of  any  particular  feptum  between  this  coat 
and  the  tefticle  :  this,  it  is  of  importance  to  notice,  as 
the  difeafes  of  thefe  parts  cannot  otherwife  be  under- 
ftood. 

As  the  difeafes  we  are  now  to  confider  are  chiefly 
feated  in  the  coverings  of  the  teflis,  I  have  given  a 
more  particular  account  of  them,  than  is  neceflary  in 
fpeaking  of  the  teftis  itfelf ;  with  refpect  to  which,  I 
{hall  only  obferve,  that  it  is  evidently  very  vafcular, 
being  compofed  almoft  entirely  of  diiferent  convolu* 
tions  of  veflels. 

Befides  the  vaginal  coat  proper  to  each  tefl:icle,  the 
two  teftes  have  for  their  further  proteftion,  a  more 
external  covering,  the  fcrotum  ;  a  bag  formed  almoft 
entirely  of  fkin  and  cellular  fubflance  ;  for  that  body, 
the  dartos,  which  has  been  commonly  dcfcribed  as 
mufcular,  is  now  clearly  proved  to  be  altogether  cel- 
lular. Even  the  feptum  fcroti,  or  that  membrane 
which  divides  one  tefticle  from  another,  is  compofed 
of  cellular  fubltance  in  a  more  condenfed  ftate.  By 
air  it  is  eafily  inflated,  and  it  is  alfo  pervious  to  water  ; 
fo,  of  courfe,  it  partakes  of  all  thofe  watery  eft'ufions, 
to  which  the  more  external  parts  of  the  fcrotum  are 
liable. 

This  ftrudure  of  the  fcrotum  it  i^  necefl!ary  to  be 
acquainted  with,  as,  from  the  defcriptions  which,  till 
of  late,  have  been  given  of  it,  young  practitioners  are 
induced  to  confider  it  as  mufcular,  and  to  fuppofe  that 
the  feptum,  with  its  rapha,  are  ligamentous  ;  and  hence 
they  are  led  to  be  more  cautious  than  they  need  be  in 
performing  operations  on  this  part. 

Having  thus  premifed  an  account  of  the  anatomy 
of  the  parts  in  which  the  water  in  hydrocele  is  collect- 
ed, I  fhall  now  proceed  to  confider  the  difl;'erent  vari,, 
eties  of  the  difeafe. 


40  On  the  Hydrocele.  Chap.  XXIV. 

All  the  varieties  of  hydrocele  which  have  been  men- 
tioned by  authors,  mav,  I  think,  be  comprehended 
\inder  the  two  loUowing,  the  anafarcouSy  and  encyfted. 

In  the  former,  the  ferum  is  difFufed  over  all  the  fub- 
ftance  of  the  part  in  which  it  is  feated ;  it  is  not  col- 
lected in  any  particular  cavity,  but  occupies  equally 
all  the  cells  of  the  part :  in  that  which  I  term  encyft- 
ed,  tiie  warer  is  collected  in  one  diftinct  bag,  and  a 
fluclLHition  of  a  fluid  is,  in  general,  perceived  in  it. 
The  fcrotum,  with  its  contents,  the  teflicle  and  its  ap- 
pendages, are  liable  to  both  varieties  of  the  difeafe  ; 
and  the  fpermatic  cord,  with  its  coverings,  are  alfo  li- 
able to  both.  We  Ihall  fnlt  confider  thofe  of  the 
fcrotam. 


SECTION     II. 

Of  the  Anafarcous  Hydrocele  of  the  Scrotum, 

T'HE  fcrotum,  from  its  cellular  ftrudlure,  and  im- 
mediate connedticn  v/ith  the  trunk  of  the  body, 
is  apt  to  partake  of  every  difF''^:ibls  fvvelling  v/ith  which 
the  upper  part  of  the  body  is  attacked  :  and,  accord- 
ingly, we  find,  that  general  anafarcous  fwellings  fel- 
dom  fubfift  for  any  length  of  time,  without  aftecling 
the  fcrotum.  A  local  anafarca  of  the  fcrotum,  is 
fometimes  indeed  produced  by  a  local  caufe,  to  wit, 
by  the  prcfiare  of  a  tumor  on  the  lymphatics  of  the 
part ;  by  external  injuries  ;  and  occafionally  by  an 
effufion  of  urine  from  a  rupture  of  the  urethra  :  but 
fuch  occurrences  are  rare  ;  a  general  difeafe  of  the 
conftitution  being  the  ufual  forerunner  of  thefe  tu- 
mors. 

As  foon  as  water  has  collected  In  any  confiderable 
quantity  in  the  fcrotum,  a  foft,  ineladic,  colourlefs  tu- 
mor is  obferved  over  the  whole  of  it ;  imprefiions  are 
eafily  received  and  retained  for  fome  time  ;  the  fkin 


Sea.  n.  Gn  the  Hydroceb.  .  41 

at  firfl  preferves  Its  natural  appearance  ;  and  the  ru- 
t^as  of  die  Icrotiim,  which,  in  a  ftate  of  health,  are  ob- 
vious, are  not  for  fome  time  much  altered  ;  but  as  the 
fweliing  advances,  the  rugj^  gradually  disappear,  till 
at  hill  they  are  totally  obliterated  :  the  tumor,  from 
being  at  firfl  foft,  and  of  a  confiflence  fimilar  to  dough, 
by  degrees  turns  more  firm,  and  the  fkin  at  lafl  ac- 
quires an  unnatural  white  fl:uning  appearance.  At 
length  it  becomes  large  ;  and  although  originally  con- 
fined to  the  fcrorum,  it  at  lafi:  fpreads  up  the  groin  : 
the  penis  likewifc  becomes  afltxted,  and  often  fo  fwell- 
ed  and  diftorted,  as  to  excite  much  inconvenience  and 
diftrefs  ;  and  although  the  fcrotum  is  compofed  of 
parts  which  readily  adijiit  of  dilatation,  yet,  in  fome 
inlfanccs,  the  tumor  becomes  fo  enormous,  as  to  burfl 
from  one  end  to  the  other. 

Thefe  appearances  of  the  difeafe  are  fo  charafterif- 
tic,  as  to  render  it  almoft  impolTible  to  confound  this 
fpecies  of  hydrocele  with  any  other  tumor  of  the  fcro- 
tum. 

I  have  already  obfcrvcd,  that  inflances  fomctimes 
occur,  of  the  fcrotal  anafarca  being  produced  by  a  lo- 
cal caufe  ;  but,  in  a  great  proportion  of  cafes,  it  is  in- 
duced by  a  general  tendency  to  dropfy  ;  fo  that  the 
cure  will  chiefly  depend  upon  the  removal  of  that  hab- 
it of  body,  by  which  it  was  at  firft  produced. 

The  treatment  of  this  difeafe  of  the  fyfbem  falls  to 
the  province  of  the  phyfician,  fo  that  I  fliall  not  enter 
upon  it  at  prefent ;  but  the  aid  of  furgery  is  frequent- 
ly required,  for  relieving  the  diftrefs  which  thefe  tu- 
mors always  induce  when  they  become  large.  In  thefe 
circumftances,  the  objeft  of  furgery  is,  by  drawing  off 
the  water,  to  diminiil-i  the  fize  of  the  tumor,  or  even 
to  remove  it  altogether,  which  not  only  gives  much 
immediate  relief,  but  is  a  means  of  the  diftended  parts 
recovering  their  tone  more  readily  than  they  otherv^'ife 
would  do.  Diiferent  methods  have  been  prcpofed  for 
evacuating  the  water ;  the  introdudion  of  a  feton,  pafT- 
ing  a  trocar,  incifions,  and  punclures. 


42  On  the  Hydrocele,  Chap.  XXIV. 

All  of  thefe,  excepting  that  by  the  trocar,  ferve  ve- 
ry effectually  to  evacuate  the  diffufed  water  ;  and 
therefore  we  are  to  adopt  that  which  not  only  excites 
leaft  pain,  but  which  is  leafl:  liable  to  produce  trouble- 
fome  confequences  ;  and  this  unqueflionably  is  the 
method  by  punctures. 

The  fetou  and  long  fcarifications  may  difcharge  the 
water  more  quickly  than  punctures  ;  but  in  dropfical 
conftitutions,  fuch  as  the  anafarcous  hydrocele  is  com- 
monly connected  with,  they  almoft  conftantly  do  harm. 
For  the  firfl  two  or  three  days,  fcarifications  give>  the 
patient  much  fatisfadtion  :  the  v/ater  is  almoft  entirely 
discharged,  the  tumor  is  of  courfe  greatly  diminiflied, 
and  much  relief  is  thereby  obtained.  About  this  time, 
however,  the  fcarified  parts  commonly  begin  to  fret, 
their  edges  turn  hard  and  inflamed,  and  by  degrees, 
an  eryfipelatous  rednefs  fpreads  over  the  neighbouring 
parts. 

That  fretful  uneafmefs  at  firft  complained  of,  ter- 
minates at  laft  in  what  the  patient  terms  a  burning 
kind  of  pain,  which  frequently  becomes  fo  tormenting, 
as  entirely  to  deilroy  reft  ;  and  it  too  commonly  hap- 
pens, that  all  our  remedies  fail  in  preventing  the  ac- 
ceflion  of  gangrene,  by  which  the  patient  is  in  gener- 
al carried  off. 

I  will  not  fay  that  fcarifications  always  end  in  this 
fatal  way  ;  but  I  have  in  many  inftances  found  that 
they  did  fo  ;  and,  on  the  contraiy,  although  punctures 
fometimes  terminate  in  the  fame  manner,  they  are  by 
no  means  fo  ready  to  do  fo. 

As  fcarifications  are  fo  apt  to  do  harm,  there  is  much 
reafon  to  fufpect  that  the  trocar  and  feton,  which  both 
excite  ftill  more  irritation,  would  prove  ftill  more  hurt- 
ful. They  are  now,  accordingly,  in  the  anafarcous 
hydrocele  very  generally  laid  afide. 

When  fcarifications  are  to  be  employed,  we  make 
them  with  the  flioulder  of  a  lancet  :  they  ftiould  pen- 
etrate the  cutis  vera,  but  ftiould  not  be  carried  to  a 
greater  depth,  ar.d  they  fnould  not  exceed  an  inch  in 


8e£l.  11.  On  the  Hydruek.  43 

< 

length  :  pun6liires  flioiild  be  carried  to  the  fame  depth  ; 
and  they,  as  well  as  fcarifications,  fliould  be  always  on 
the  molt  prominent  and  moft  depending  parts  of  the 
tumor  :  punftures  are  bell  made  with  the  point  of  a 
lancet :  live  or  fix  are  commonly  fufficient  at  once  ; 
but  as  they  are  apt  to  heal  before  the  ferum  is  all  dif- 
charged,  they  require  from  time  to  time  to  be  re- 
newed. 

Preferving  the  parts  dry,  by  a  frequent  renewal  of 
dry  linen  cloths,  in  order  to  imbibe  the  moifture,  is 
here  a  very  necefl'ary  attention  ;  indeed,  the  want  of 
it  feems  often  to  be  the  caufe  of  much  of  the  niifchief 
that  enfucs  from  this  operation. 

When  cither  fcarifications  or  punftures  go  wrong, 
by  beginning  to  inflame  and  turn  painful,  inftead  of 
the  warm  emollient  poultices  and  fomentations  ufually 
employed,  a  cold  faturnine  folution  applied  upon  foft 
linen,  not  only  proves  more  effeclual  in  putting  a  flop 
to  the  inflammation,  but  affords  more  immediate  re- 
lief to  the  prefent  diftrefs.  Lime  water,  employed  in 
the  fame  manner,  proves  alfo  an  ufeful  application. 

Mortification,  however,  will  take  place  in  fome  in- 
flances,  notvvithftanding  all  that  we  can  do  to  prevent 
it :  in  this  cafe,  we  truft  chiefly  to  the  internal  ufe  of 
bark,  wine,  and  other  tonics,  and  to  warm  drelTings 
and  other  external  applications  ufually  employed  in 
gangrene  :  as  this  variety  of  gangrene  is  almofh  always 
accompanied  with  much  irritation,  I  often  give  opium 
with  advantage  :  opium  proves  chiefly  ufeful,  by  re- 
moving pain  and  general  irritability  ;  but  as  we  know 
from  experiment,  that  it  afts  as  an  antifeptic,  it  may 
in  fome  cafes  ftop  the  progrefs  of  gangrene,  by  afting 
directly  on  the  difeaied  parts. 

In  a  great  proportion  of  cafes,  the  utmofl:  danger  is 
to  be  dreaded  from  the  punctured  parts  being  attack- 
ed with  gangrene  ;  yet,  in  a  few  inflances,  very  unex- 
pected cures  are  obtained,  after  all  the  teguments  have 
been  deflroyed  by  it.  A  remarkable  inflance  of  this 
occurred  fome  years  ago,  in  the  Royal  Infirmary  here  ; 


44  On  ihe  Hydrocele.  Chap.  XXIV. 

the  whole  fcrotum  feparatcd,  and  left  the  tefticles  bare. 
During  the  time  that  the  fore  remained  open,  all  the 
water  collected  in  other  parts  of  the  body  was  evacu- 
ated, and,  by  the  ufe  of  large  quantities  of  bark,  and 
mild  dreffings  to  the  fore,  the  patient  got  well.  In 
the  courfe  of  the  cure,  the  teiles  became  enveloped 
with  a  thick  cellular  fubdance,  which  ferved  as  a  very 
good  means  of  protedlion.  It  mud  have  been  fome 
fimilar  produdlion,  I  fuppofe,  which  Hildanus  fpeaks 
of  as  a  regenerated  fcrotum.* 

I  have  already  obferved,  that,  although  the  anafar- 
cous  hydrocele  depends,  for  the  moft  part,  on  a  ge- 
neral tendency  to  dropfy,  that  fome  inflances,  howev- 
er, occur,  of  a  local  caufe  producing  a  mere  local  drop- 
fy of  the  fcrotum.  Thus  it  has,  in  fome  inftances, 
arifen  from  tumors  in  the  groin  and  abdomen  obftruci:- 
ing  the  pafTage  of  the  lymphatics.  In  this  cafe,  if  the 
tumors  producing  the  obftruftion  can  be  extirpated, 
no  other  means  will  afford  fuch  effectual  relief;  but, 
when  fo  deeply  feated  as  to  render  any  attempt  for  re- 
moving them  unfafe,  the  practice  I  have  pointed  out, 
of  making  punftures  in  the  moil  depending  part  of 
the  tumor,  rnull  be  employed,  from  time  to  time,  to 
palliate  the  fymptoms. 

It  has  fomctimes  happened,  in  fuppreffion  of  urine, 
whether  arifing  from  ftri6tures  in  the  urethra,  or  from 
ftones  impacted  in  it,  that  the  urethra  has  burft,  and 
the  urine,  in  this  manner,  getting  accefs  to  the  cellu- 
lar texture  of  the  fcrotum,  an  anafarcous  fwelling  rifes 
immediately  over  the  whole  of  it ;  nor  does  it  com- 
monly diminiih  till  the  caufe  by  which  it  is  produced 
is  removed. 

In  order  to  prevent  the  formation  of  finufes,  which, 
in  fuch  circumilances,  v/iil  otherwife  be  apt  to  occur, 
an  incifion  Ihould  be  made  into  the  moft  depending 
part  of  the  fcrotum,  and  carried  to  fuch  a  depth  as  is 
fufiicieiit  for  reaching  the  wound  in  the  urethra.     In 

•  Olfcrvat.  Chirurg.  Cent.  5,  Obf.  76* 


Sed.  It  Oh  the  Hydrocele,  45 

this  manner,  a  free  vent  will  not  only  be  given  to  the 
•urine  ah-eady  diflufed,  but  the  further  colleclion  of  it 
may  probably  be  prevented.  If  a  (tone  impacted  in 
the  urethra  is  found  to  be  the  caufe  of  the  eft'ufion,  it 
fhould  be  cut  out ;  and,  if  the  obflruclion  is  produced 
by  llridlures,  they  muft  be  removed  by  a  proper  ufe 
of  bougies.  The  caufe  being  thus  removed,  if  the 
habit  of  body  of  the  patient  is  good,  and  untainted 
with  any  venereal  or  other  general  aft'eftion,  by  dreff- 
ing  the  fore  properly,  with  foft  eafy  applications,  the 
opening  in  the  urethra  will  probably  heal,  and  a  com- 
plete cure  will,  in  this  manner,  be  obtained.  But 
when  thefe  ailments  are  complicated  with  any  general 
affeftion,  particularly  with  lues  venerea,  neither  mer- 
cury nor  any  other  internal  medicine,  will  remove 
them. 

Cafes  of  this  kind  mufl  have  occurred  to  every  prac- 
titioner. I  have  met  with  them,  both  in  the  hofpital 
and  in  private  pradice ;  where,  notwithftanding  all 
the  internal  remedies  that  v/ere  employed,  the  paflage 
from  the  urethra  remained  open,  and  continued  to  af- 
ford a  vent  to  the  urine.  In  fuch  cafes,  we  depend 
chiefly  upon  a  proper  application  of  bougies. 

The  fcrotal  anafarca,  of  a  local  nature,  has  alfo  hap- 
pened from  the  rupture  of  a  hyi'ocele  of  the  tunica 
vaginalis  teftis :  when  the  hydrocele  of  the  tunica  va- 
ginalis arrives  at  a  great  fize,  jumping  from  a  height, 
or  a  violent  blow  or  bruife,  will  readily  burft;  it ;  and 
the  water,  not  finding  a  palTage  outwardly,  muft  ne- 
ceffarily  dift'ufe  itfelf  over  the  fcrotum.  Different  in- 
ftances  of  this  have  been  met  with,  tv/o  of  which  are 
related  by  Douglas  ;*  and  others  have  fliUen  within 
my  own  obfervation.  A  fwelling  of  a  fimilar  kind  is 
alfo  fometimes  induced  by  the  w-ater  of  the  hydrocele 
of  the  tunica  vaginalis  being  improperly  drawn  oli  in 
the  operation  of  tapping.  When  the  orifice  in  the 
fkni  is  allowed  to  recede  from  the  opening  in  the  va> 

"  Trcitifi:  «a  the  Hydrocele,  by  John  Douglas,  p.  8. 


46  On  the  Hydrocele.  Chap.  XXIV. 

ginal  coat  before  the  water  is  all  difcharged,  as  is  apt 
to  happen  when  the  operation  is  done  with  a  lancet, 
the  remainder  of  the  collection  difiufes  itfelf  through 
the  cellular  fubftance  of  the  fcrotum,  an  inconveni- 
ence that  may  be  always  prevented,  by  ufmg  a  trocar 
for  this  operation,  inftead  of  a  lancet. 

In  whatever  way  the  fwelling  is  produced,  the  cure 
fliould  confift  in  laying  the  tumor  fufficiently  open, 
not  only  for  evacuating  the  diftufed  ferum,  but  for  ef- 
fecting a  radical  cure  oi  the  hydrocele  of  the  tunica 
vaginalis. 

Some  have  imagined,  that  danger  may  enfue  from 
performing  the  radical  cure  for  the  hydrocele  in  this 
fituation  ;  but  I  have  done  it  in  different  inftances, 
and  no  harm  has  ever  enfued  from  it.  The  patient, 
in  fome  cafes,  may  decline  the  operation,  and,  in  oth- 
ers, his  habit  of  body  may  render  it  improper ;  but, 
when  this  does  not  happen,  few  will  doubt  of  its  be* 
ing  better  to  give  a  patient,  in  fuch  circumftances,  im- 
mediate and  eifedual  relief,  by  performing  the  radical 
cure  at  once,  than  to  fubjecl  him,  in  the  firil  inftance, 
to  a  good  deal  of  confinement,  for  removing  the  dif- 
fufed  fwelling  of  the  fcrotum,  and  to  leave  him  under 
the  fame  neceffity  as  before,  of  fubmitting  to  the  radi- 
cal cure  for  the  hydrocele  of  the  tunica  vaginalis. 

When,  for  either  of  the  reafons,  however,  that  I 
have  mentioned,  this  operation  is  not  to  be  perform- 
ed, we.  endeavour  to  aflifl  the  difcuffion  of  the  tumor, 
by  fufpending  the  fcrotum  ;  confining  the  patient  to  a 
horizontal  pofture ;  and  by  the  apphcation  of  aftrin- 
gents  to  the  parts  affected.  Of  thefe  we  have  a  great 
variety  ;  but  1  have  found  none  anfwer  fo  well  as  a 
cold  folution  of  crude  fal  ammoniac,  in  the  proportion 
of  half  an  ounce  of  the  fait  to  a  pound  of  water  and 
two  ounces  of  vinegar ;  or  poultices,  prepared  with 
crumb  of  bread,  foakcd  in  equal  parts  of  cold  water, ^ 
vinegar,  and  brandy. 

I  have  thus  confidered  all  the  varieties  of  anafar- 
cous  tumors,  to  which  the  fcrotum  u  liable,  together 


Se6t.  IL  On  the  Hydrocele.  47 

with  the  mode  of  treatment  that  appears  to  be  adapt- 
ed to  each  of  them  ;  for,  with  refpeft  to  the  hydro- 
cele of  the  dartos,  a  difeafe  particularly  defcribed  by 
ancient  writers,  as  that  part  of  the  fcrotum  is  now- 
known  to  be  entirely  cellular,  fo  any  water  collected 
in  it  muft  tend  to  form  that  very  difeafe  we  have  juft 
been  defcribing,  an  anafarcous  fwelling  of  the  whole 
fcrotum. 

We  now  proceed  to  confider  that  fpecies  of  hydro- 
cele which,  from  being  feated  within  the  cavity  of  the 
fcrotum,  may  be  termed  the  encyftcd  hydrocele  of  the 
fcrotum.  Of  this  there  are  two  varieties,  the  hydro- 
cele of  the  tunica  vaginalis  teftis,  and  that  fpecies  of 
tumor  formed  by  water  coUeded  in  the  fac  of  a  her- 
nia. 


SECTION     III. 

Of  the  Hydrocele  of  the  Tunica  Vaginalis  Tejlis* 

WHEN  treating  of  the  anatomy  of  thefe  parts, 
I  had  occafion  to  remark,  that,  in  a  (late  of 
health,  an  aqueous  fecretion  is  always  found  in  the 
tunica  vaginalis  ;  the  principal  ufe  of  which  feems  to 
be,  to  lubricate,  and  keep  thq  furface  of  the  tefticle 
foft  and  eafy. 

In  a  flate  of  health,  this  fluid  is  abforbed  by  the 
lymphatics  of  the  part,  its  place  being  fupplied  by  a 
frefli  fecretion  ;  but,  m  difeafe,  it  frequently  happens, 
either  that  the  fecretion  of  this  fluid  is  morbidly  in- 
creafed,  or  the  powers  of  the  abforbing  veflels  of  the 
part  arc  diminiflied.  The  efictt  of  either  of  thefe 
caufes  muft  be,  to  induce  a  preternatural  colleftion  in 
the  cavity  of  the  vaginal  coat ;  and  thus  the  variety 
of  hydrocele  is  produced  that  we  are  now  to  confider. 

The  fyniptoms  induced  by  it  are  thefe  :  a  foft  col- 
ourlefs  tumor  is  at  firft  perceived  at  the  inferior  point 


48  On  the  Hydrccclc.  Chap.  XXIV/ 

t)f  the  tefticle  ;  chiefly  remarkable  when  the  patient  is 
erecl :  it  excites  no  pain,  and  it  does  not  become  leis 
by  prcfTure.  The  fliape  of  the  tumor  is  at  firft  nearly 
globular  ;  but  it  afterwards  becomes  pyramidal,  being 
larger  below  than  above :  as  it  advances  in  fize,  it  be- 
comes proportionally  more  tenfe,  and  the  natural  ru- 
gae of  the  fcrotum  lefs  perceptible.  For  a  confidera- 
ble  time,  it  does  not  extend  farther  than  the  ufual 
boundaries  of  the  fcrotum ;  but,  on  longer  continu- 
ance, it  advances  to  the  abdominal  mufcles  :  fo  that, 
although  in  the  early  periods  of  the  difeafe,  the  fper- 
matic  cord  may  be  dillinctly  felt ;  in  its  more  advanc- 
ed ftate,  it  is  not  eafily  diftinguilhed. 

Before  arriving  at  this  height,  the  weight  of  the  tu- 
mor is  for  the  mofh  part  conaiderable,  by  which  the 
fkin  of  the  contiguous  parts  is  dragged  fo  much  down- 
wards, as  to  make  the  penis  flirink  confiderably,  and 
fometimes  difappear  almoft  entirely.  In  this  advanc- 
ed ftate  of  the  difeafe,  the  tefticle,  which  ufually  lies 
at  the  back  part  of  the  tumor,  and  which,  for  fome 
time  after  its  commencement,  could  be  diftindly  felt, 
is  not  fo  clearly  difcovered.  On  minute  examination, 
however,  a  hardnefs  may  always  be  felt  along  that  part 
of  the  fcrotum  where  the  teflis  is  fituated  ;  and  at 
this  point,  preifure  excites  fome  degree  of  uneafmefs. 

In  a  great  proportion  of  cafes,  the  fluctuation  of  a 
fluid  is  obviouily  diftinguifhed  on  prefl^ure.  It  fome- 
times happens,  hovv^ever,  in  that  tenfe  ftate  of  the  tu- 
mor, ufually  produced  by  a  long  continuance  of  the 
difeafe,  that  the  fluid  contained  in  it  is  not  evidently 
difcovered  :  nor,  in  this  fttuation,  is  the  ordinary  cha- 
racleriftic  mark  of  hydrocele  more  to  be  depended 
on  ;  I  mean  the  tranfparcncy  of  the  tumor,  when  ex- 
pofed  to  the  light  of  a  candle,  or  of  the  fun.  In  the 
fc^.-.ly  ftages  of  the  difeafe,  when  the  contents  of  the 
tumor  are  not  difcoloured,  and  the  vaginal  coat  has 
not  acquired  much  thicknefs,  the  fluid  contained  in  it, 
on  being  expofcd  to  this  trial,  ufually  appears  tranf- 
parent  j  and,,  in  meeting  with  this,  we  ncccif:irily  con- 


SeS:.  III.  On  the  Hydrocele,  49 

fider  it  as  a  corroborating  proof  of  the  exiflence  of 
ferum.  The  abfence,  however,  of  this,  is  not  a  proof 
of  the  contrary  ;  for,  as  the  tranfparency  of  the  tu- 
mor depends  entirely  on  the  nature  of  its  contents, 
and  on  the  thicknefs  of  its  coverings,  whatever  tends 
to  render  the  one  lefs  clear,  and  the  other  of  a  more 
firm  texture,  mufl,  in  proportion  to  this  effect,  inval- 
idate the  certainty  of  the  tefl. 

During  the  whole  continuance  of  the  difea^e,  the 
patient  does  not  complain  of  pain  in  the  tumor  itfelf ; 
but  fome  uncafmefs  is  commonly  felt  in  the  back,  by 
the  weight  of  the  tumor  on  the  fpermatic  cord.  This, 
however,  is  generally  prevented  cntirelv,  or  much  al- 
leviated, by  the  ufe  of  a  fufpenfory  bandage. 

Thefe  are  the  ufual  appearances  of  a  hydrocele  when 
confined  to  one  fide  of  the  fcrotum.  In  fome  inflan- 
ces,  however,  we  meet  with  a  double  hydrocele,  when 
the  tumor  occupies  the  cavities  of  both  tunicce  vagi- 
nales,  and  inftead  of  being  confined  to  one  fide  of  the 
fcrotum,  extends  equally  over  the  whole  of  it. 

As  this  variety  of  hydrocele  is  fometimes  confound- 
ed with  other  difeafes,  it  is  particularly  neceffary  to 
hold  fuch  circumftances  in  view,  as  mod  certainly 
tend  to  charadlerize  and  diftin^uifli  them.     Thefe  dif- 

o 

ea^cs  are,  all  the  varieties  of  fcrotal  hernies  ;  the  ana- 
farcous  hydrocele  of  the  fcrotum  ;  the  encyfi;ed  hy- 
drocele of  the  fpermatic  cord  ;  the  farcocele,  or  fchir- 
rous  teilicle  ;  and  the  hernia  humoralis,  or  inflamed 
teflis. 

In  the  hydrocele  of  the  tunica  vaginalis,  the  tumor 
begins  at  the  bottom  of  the  fcrotum,  and  proceeds 
flowly  upwards.  It  is  of  a  fmooth  equal  furface.  In 
a  great  proportion  of  cafes  the  fpermatic  cord  is  felt 
at  the  upper  part  of  it,  and  the  fluctuation  of  a  fluid 
is  diltingiiifiied  through  its  whole  extent.  Prefigure 
does  not  make  the  fwelling  recede,  nor  is  it  afiecled 
by  the  pofture  of  the  patient,  if* it  be  not  on  its  very 
firfl:  approach  :  whereas,  in  hernia,  befides  pain,  fick- 

VoL.  III.  E 


50  On  ihe  tlydroccJe.  Chap.  XXIV.- 

nefs,  and  other  affeclions  of  the  flomach  and  bowels 
which  commonly  take  place,  the  tumor  begins  in  the 
groin,  and  only  at  lafl  proceeds  to  the  fcrotum.  It 
has  not  the  pyramidal  form  of  a  hydrocele.  It  is  fre- 
quently foft  and  compreflible,  giving  a  fenfation  fimi- 
lar  to  what  we  receive  from  prelfure  upon  dough  ;  but 
no  equal  or  diftinft  Hu6luation  is  perceived  in  it.  In' 
mofl  inflances,  the  tumor  can  be  made  to  recede,  ei- 
ther altogether  or  in  part,  by  moderate  preflbre,  and 
putting  the  patient  in  a  horizontal  pollure ;  and  irk 
hernia  dcfcending  to  the  fcrotum,  the  fpermatic  cord 
can  never  be  clearly  diftinguiflied. 

However  improbable  it  may  appear,  this  variety  of 
hydrocele  has,  in  fome  inflances  been  confounded  with 
anafarcous  tumors  of  the  fcrotum  ;  but  the  means  of 
diilindion  are  fo  evident,  from  the  hiftory  which  I 
have  given  of  the  two  difeafes,  that  it  is  not  here  ne- 
ceflary  to  enter  farther  upon  the  fubjeft.  It  muft,  in- 
deed, be  grofs  inattention  only  that  can  ever  make 
the  anafarcous  hydrocele  be  miftaken  for  any  other 
difeafe. 

From  the  encylled  hydrocele  of  the  fpermatic  cordy 
it  may  commonly  be  diftinguiflied  by  the  teflicle  in 
the  latter  being  plainly  felt  at  the  under  part  of  the 
tumor;  whereas,  in  this  difeafe,  the  teflis  is  feldonx- 
dlfLlndlly  perceived  if  it  be  not  at  the  back  part  of  the 
tumor.  In  two  cafes,  I  have  met  with  the  tefticle  on 
the  anterior  part  of  a  hydrocele  ;  and,  in  a  third,  al- 
though fixed  behind  in  its  ufual  fituation,  it  alfo  ad- 
hered at  one  point  to  the  middle  and  anterior  part  of 
the  tunica  vaginalis.  I'his  I  fufpeded  to  be  the  effed: 
of  inflammation,  induced  either  by  hernia  humeralis 
or  fome  other  difeafe  ;  and  on  inquiry,  it  appeared  that 
the  patient  at  one  time  had  been  long  confined  with 
inflammation  of  tliis  tefl;icle,  the  effeft  of  a  bruife. 

In  the  encyfi:ed  hydrocele  of  the  cord,  the  tumor 
firfl  appears  above  the  teflicle,  and  by  degrees  fall? 
downwards  j  while  the  very  reverfe  happens  in  the  hy- 


Seft.  ni.  On  the  Hydrocele,  51 

drocele  of  the  tunica  vaginalis,  in  which  the  tumor  at 
firft  always  forms  below,  and  from  thence  proceeds 
upwards. 

.  In  a  few  inftances,  thefe  two  varieties  of  hydrocele 
have  been  known  to  exifl:  at  the  fame  time  in  the  lame 
patient.  In  this  cafe  the  ferum,  although  colleftcd  in 
two  diflinft  cyfts,  gives  the  appearance  of  one  uniform 
tumor  ;  and  a  fluctuation  is  diftindlly  felt  from  one 
end  of  it  to  the  other.  But,  in  any  inflance  that  I 
have  feen  of  this  combination,  the  tumor  has  been 
fomewhat  contraded,  having  rather  a  lefs  diameter  at 
that  part  where  the  two  colledions  are  feparated  from 
each  other  ;  fo  that,  where  this  appearance  takes  place, 
we  may,  in  general,  fufpect  that  the  ferum  is  collect- 
ed in  two  diltintt  bags.  This,  however,  does  not  al- 
ways happen  ;  for  occafionally  I  have  met  with  this 
appearance  where  the  difeafe  was  fixed  in  the  tunica 
vaghialis  alone. 

The  circumflances  which  mofl  clearly  diflinguifli 
hydrocele  from  a  fchirrous  tefticle  are  thefe :  in  the 
latter  the  fwelling  is  hard  ;  it  does  not  yield  in  any 
degree  to  prefllire ;  the  furface  of  the  tumor  is  com- 
monly rough  and  unequal ;  it  is  in  general  attended 
with  a  good  deal  of  pain,  and  is  always  heavy  in  pro- 
portion to  its  fize :  whereas,  in  hydrocele,  the  fwell- 
ing commonly  yields  to  prelTure  ;  its  furface  is  fmooth  ; 
little  or  no  pain  takes  place  j  and  the  tunior  is  light 
in  proportion  to  its  bulk. 

Thefe  ditferences  will  always  ferve  as  a  fufficient 
means  of  diflindlion  between  this  fpecies  of  hydrocele 
and  a  pure  unmixed  farcoccle.  But  when  a  fchirrous 
tefticle  is  combined  with  an  eflufion  of  water  into  the 
tunica  vaginalis,  forming  what  has  very  properly  been 
termed  a  hydro-farcoccle,  the  means  of  diflinction  are 
not  fo  obvious.  In  the  incipient  ftate  of  thefe  efFu- 
fions,  the  difference  between  the  two  difeafes  is  fuf- 
ficiently  apparent  j  but,  when  far  advanced,  the  mod 
attentive  obferver  often  finds  it  difficult,  and  fometimes 

£   2 


52  0?i  the  Hydrccek,  Chap.  XXIV. 

impofiible,  to  mark  the  diftindlon.  In  fuch  doubtful 
cafes,  however,  by  proceeding  in  the  cautious  manner 
to  be  afterwards  pointed  out,  no  detriment  will  occur 
to  the  pati;::nt,  from  any  uncertainty  that  may  take 
place. 

From  the  hernia  Iiumeralis,  this  fpecies  of  hydro- 
cele is  eafily  diftinguifhed.  In  the  former,  the  tumor 
fucceeds  either  immediately  to  fome  external  bruife, 
or  it  is  evidently  the  confequence  of  a  gonorrhoea,  or 
of  fome  other  inflammatory  affection  of  the  urethra.* 
The  (kin  is  more  or  lefs  afte<Sted  with  an  inflammato- 
ry rednefs ;  it  is  attended  with  much  pain,  efpecially 
on  being  handled,  and  the  tumor  is  hard  and  hrm,  fo 
that  no  fluctuation  is  felt  in  it,  unlefs  in  its  more  ad- 
vanced ftate,  when  fuppuration  fometimes,  although 
rarely,  takes  place  between  the  fcrotum  and  tefticle ; 
in  which  cafe,  the  ufual  fymptoms  of  abfcefs,  particu- 
larly the  pointing  of  the  tumor,  and  its*  being  much 
difcoloured,  ferve  to  diftinguifli  it. 

In  forming  a  prognofis  of  this  difeafe,  v/e  fliould  be 
chiefly  directed  by  the  habit  of  body  of  the  patient. 
In  a  great  proportion  of  cafes  we  are  to  confider  it  as 
a  local  affedion  j  and,  in  this  fl:ate  the  mofl  fiivoura- 
ble  expedations  may  be  formed  of  it.  For,  whatever 
may  have  been  alleged  by  fome,  of  the  hazard  of  eve- 
ry operation  for  a  radical  cure,  in  a  fimple  unmixed 
hydrocele,  if  the  confl.itution  is  not  very  unhealthy,  it 
may  at  all  times  be  advifed  with  a  very  fair  profpe(5t 
of  fuccefs. 

In  the  radical  cure  of  the  hydrocele,  in  whatever 
way  it  is  done,  fome  pain  wdll  be  excited ;  the  parts 
will  inflame,  and  of*  courfe  fome  degree  of  fever  will 
take  place.  In  fome  inltances,  thefe  fymptoms  have 
gone  rather  fartlier  than  was  v/ifhed  for ;  but,  under 
the  limitations  I  have  mentioned,  of  an  unmixed  flate 

*  The  operation  of  lithotomy  is  frccu.ently  attended  ■'.\-5t}i  an  inflamma- 
tion cf  one,  and  fometimes  of  both  teflicles ;  probabiv  from  the  inflam- 
miuion  induced  by  the  operation  in  the  neighbourhood  of  the  caput  gal- 
linaginis,  bcin?  cDmmunicated  along  the  vas  deferens  to  the  tcllis. 


Sed.  IIL  On  the  Hydrocele.  53 

of  the  difeafe,  in  a  conflltution  otherwife  healthy,  the 
operation  I  lliall  prefently  defcrihe,  when  properly 
performed,  and  the  cure  thereafter  rightly  conduded, 
never  fails  of  the  moft  complete  fuccefs,  while,  in  no 
inftance,  has  it  ever,  in  the  courfe  of  my  experience, 
proved  fatal. 

But,  on  the  contrary,  in  conftitutions  otherwife  dif- 
eafed,  in  very  aged  people,  and  in  infirm  habits  of 
body,  we  are  by  no  means  to  expeft  fuch  certain  fuc- 
cefs :  even  in  fuch  circumftances,  however,  the  opera- 
tion often  fucceeds.  I  have,  in  various  inflances,  per- 
formed it  under  one  or  other  of  thefe  difadvantages, 
and  I  never  knew  it  fail.  Others,  however,  have 
found  that  it  has  done  fo  ;  and  it  may  readily  be  fup- 
pofed,  when  pradifed  upon  the  old,  infirm,  and  dif- 
eafed,  that  the  fymptomalic  fever  may  run  too  high 
for  the  flrength  of  the  patient ;  and  that  the  fuppura- 
tion  produced  by  a  high  degree  of  inflammation,  may 
afterwards  tend  to  deftroy  the  remains  of  a  conftitu- 
tion  already  greatly  impaired.  This,  however,  fhould 
not  be  laid  to  the  account  of  the  operntion,  but  to  the 
impropriety  on  the  part  of  furgeons,  in  advifing  it  in 
patients  already  perhaps  in  danger  v/ith  other  difeafes. 
In  fuch  circumflances,  no  operation  fliould  be  per- 
formed, and  the  patient  fliould  be  defired  to  truft  en- 
tirely to  a  proper  ufe  of  a  fufpenfory  bandage. 

In  judging  therefore  of  the  event  of  a  hydrocele,  I 
would  fay,  that  in  conflitutions  fuch  as  the  operation 
fhould  be  advifed  in,  fcarcely  any  danger  is  to  be 
dreaded ;  while,  on  the  contrary,  in  the  infirm,  and 
efpecially  in  fuch  as  are  otherwife  unhealthy,  that 
fome  rifk  will  occur  from  any  operation  we  can  pro- 
pofe,  and  that  the  degree  of  rifk  will  be  nearly  in  pro- 
portion to  the  nature  and  extent  of  that  diftafe  with 
which  the  conflitution  is  aifeded. 

As  long  as  a  hydrocele  keeps  within  moderate  lim- 
its, patients  in  general,  rather  fubmit  to  the  inconve- 
nience than  undergo  the  pain  of  an  operation  ;  at  leaft 
this  is  commonly  the  cafe  with  people  of  rank,  Vv'ho 


54  On  the  Hydrocck.         Chap.  XXIV. 

can  more  readily  fubmlt  to  any  diftrefs  which  it  ex- 
cites, than  patients  of  a  poorer  clafs,  whofe  labour  is 
frequently  impeded  by  the  fize  of  the  tumor.  At  laft, 
however,  by  its  bulk,  it  excites  in  all  a  ftrong  defire 
to  have  it  removed  ;  for,  befides  the  defire  naturally 
implanted  in  all  mankind,  to  be  found  and  entire  in 
thefe  parts,  the  water  colle£ted  in  a  hydrocele,  is,  in 
fomc  inflances  fo  very  confiderable,  as  to  be  the  caufe 
of  much  inconvenience.  When,  from  timidity,  or  any 
other  caufe,  the  operation  has  been  too  long  delayed, 
I  have  known  the  tumor  become  fo  large,  as  in  courfe 
of  time  to  cover  a  confiderable  part  of  each  thigh,  and 
in  length  to  extend  from  the  groin  to  the  knee. 

Various  methods  have  been  propofed  for  the  cure 
of  hydrocele  ;  all  of  which,  however,  may  be  reduced 
to  two  :  fuch  as  have  in  view  only  a  temporary  relief, 
and  which  is  therefore  termed  the  palliative  cure  ;  and 
fuch  as  are  meant  to  effect  a  radical  cure,  or  a  final 
removal  of  the  difeafe. 

Whatever  advantages  may  be  experienced  from  the 
life  of  internal  medicines,  in  dropfy  of  the  conftitu- 
tion,  no  practitioner,  I  beheve,  has  fo  much  confidence 
in  remedies  of  this  clafs,  as  to  expect  much  advantage 
from  them  in  encyfted  dropfy  of  any  kind.  We  have 
daily  proofs  of  their  failure  in  partial  hydropic  collec- 
tions, wherever  they  are  feated  ;  and  in  none  more 
ftequently  than  in  the  hydrocele. 

We  are  told,  indeed,  of  this  difeafe  being  cured  by 
different  medicines,  particularly  by  the  ufe  of  draflic 
purgatives ;  but,  although  I  have  often  known  them 
employed,  it  was  never  with  any  advantage,  and, 
when  pufhed  to  any  extent  they  are  fure  to  do  harm. 
As  it  is  always  proper,  however,  to  confine  the  pa- 
tient to  bed  for  fome  time  after  any  operation  of  im- 
portance, in  order  to  prevent  him  from  being  after- 
wards difturbed,  his  bowels  fhould  be  emptied  by  a 
purge  immediately  before  any  operation  for  the  radi- 
cal cure  of  a  hydrocele  is  performed  ;  but  this  is  al- 
mofl  the  only  way  in  which  purgatives  can  here  prove 


Sea.  III.  On  the  Hydrocele,  SS 

ufeful.  Internal  medicines,  therefore,  being  found  in- 
effeflual  and  we  know  of  no  external  applications  to 
be  depended  upon,  we  are  to  feek  for  that  relief  from 
furgery  which  experience  fhows  it  never  fails  to  afford. 

When  the  tumor  in  the  fcrotum  has  become  fo 
large  as  to  be  inconvenient  fron\  its  fize,  if  the  patient 
either  refufes  to  fubmit  to  the  operation  for  a  radical 
cure,  or  if  his  ftate  of  health  renders  that  operation 
improper,  in  fuch  circumflances,  the  palliative  treat- 
ment, or  a  mere  evacuation  of  the  water  by  pundure, 
is  the  only  means  we  can  employ. 

Two  methods  are  propofed  for  drawing  off  the  wa- 
ter in  this  manner  ;  by  the  pundlure  of  a  lancet,  and 
piercing  with  a  trocar.  By  fome  it  is  alleged,  that  by 
the  pun6lure  of  a  lancet  the  water  can  neither  be  fo 
completely  or  fo  properly  drawn  off  as  with  a  trocar  ; 
for  the  orifice  in  the  fkin  being  apt  to  recede  from  the 
opening  in  the  tunica  vaginalis,  the  water  is  thereby 
either  ftopt  altogether,  or  it  is  apt  to  infinuate  into  the 
furrounding  parts.  By  others  again,  it  is  faid,  that 
the  difficulty  of  introducing  the  trocar  is  fuch  as  to 
render  it  hazardous  from  the  contiguity  of  the  tefti- 
cle  ;  and  inflances  are  not  wanting  to  fhow,  that  even 
in  the  hands  of  expert  furgeons,  the  teftis  has  been 
much  injured  by  a  trocar  reaching  it  in  this  operation. 
Indeed  the  ordinary  triangular  form  of  this  inftru- 
ment  makes  it  both  difficult  and  unfafe  to  introduce 
it ;  but  the  trocar,  of  a  flat  form,  an  improvement 
which  I  propofed  a  good  many  years  ago,  enters  with 
as  much  eafe  as  a  lancet.  This  inftrument  is  repre- 
fented  in  Plate  LXVII.  fig.  4.  and  in  Plate  LXXIII. 
fig.  2.  another  form  of  the  trocar  is  delineated,  with 
either  of  which,  an  opening  may  be  made  in  the  tu- 
nica vaginalis -with  perfed  fafety,  and  the  water  with 
this  inffrument  being  much  more  freely  drawn  off 
than  with  a  lancet,  by  which  effufions  are  often  pro- 
duced into  the  cellular  fubflance  of  the  fcrotum,  the 
ufe  of  a  lancet  for  this  purpofe  ffiould  therefore  be  laid 
afide. 


56  On  the  Hydrocele.  Chap.  XXIV. 

The  mfi:rument  being  fixed  on,  the  next  point  of 
importance  is  the  part  of  the  tumor  in  which  the 
puncture  fhould  be  made.  Even  in  this  fimple  ope- 
ration, an  acquaintance  with  the  anatomy  of  the  parts 
proves  ufeful.  The  teftes,  as  I  have  endeavoured  to 
fnow,  do  not  hang  loofe  in  their  vaginal  coats  ;  be- 
ing, on  the  contrary,  firmly  attached  to  them  behind. 
Hence  at  this  part,  even  in  the  largeft;  hydrocele,  no 
fluid  is  met  with  ;  fo  that  if,  through  ignorance  or  in- 
attention, the  trocar  fhould  be  inferted  here,  one  in- 
ftance  of  which  I  have  feen,  the  inftrument  would 
pierce  the  body  of  the  teftis,  while  it  would  not  lefTen 
the  tumor,  as  it  would  not  reach  the  cavity  of  the  va- 
ginal coat  in  which  the  fluid  is  collefted.  The  trocar 
fliould  be  introduced  in  the  anterior  and  mofl:  depend- 
ing part  of  the  tumor. 

The  patient  being  feated  in  a  chair,  or  on  a  table, 
with  the  fcrotum  hanging  over  the  edge  of  it,  the 
operator,  with  his  left  hand,  fliould  grafp  the  tumor 
behind,  in  fuch  a  manner  as  to  pufli  the  contained 
fluid  as  much  as  pofllble  into  the  anterior  and  under 
part  of  it.  This  being  done,  if  a  common  round  tro- 
car is  ufed,  a  fmall  opening  about  a  quarter  of  an  inch 
in  length  fliould  be  made  through  the  fl;in,  with  the 
flioulder  of  a  lancet,  on  that  point  where  the  trocar  is 
to  enter  ;  but  with  a  flat  trocar  this  precaution  of  pre- 
vioufly  dividing  the  fldn  is  unneceflary.  The  opera- 
tor now  takes  the  trocar  in  his  right  hand,  and  hay- 
ing fixed  the  head  of  it  in  the  palm  of  his  hand,  he 
places  the  forefinger  along  the  courfe  of  it,  leaving  as 
much  of  the  point  of  the  infl:rument  uncovered  as  may 
freely  penetrate  the  tunica  vaginalis  ;  and  this  being 
puflied  in,  the  ftilette  fliould  be  withdrawn  immedi- 
ately on  the  end  of  the  canula  having  entered  the  cyfl:. 
The  water  will  now  run  ofl" ;  and,  if  the  tumor  is  not 
uncommonly  large,  it  may  be  all  drawn  off^  at  once  ; 
but  when  the  fwelling  is  large,  as  the  fudden  difcharge 
of  the  fluid,  by  taking  away  too  quickly  the  fupport 
which  it  gave  to  the  veflels  of  the  teftis  and  vaginal 


Seel.  IIL  Cn  the  Hydrocele..  ^j 

coat,  might  endanger  the  rupture  of  fome  of  them,  it 
is  belter  iVom  time  io  time  to  (lop  the  flow  of  it  for  a 
few  feconds  ;  and  when  the  whole  is  thus  evacuated, 
and  the  canula  withdrawn,  a  piece  of  adhefive  plafier 
ihould  be  immediately  applied  to  the  orifice  ;  and  a 
comprefs  of  foft  linen  being  laid  over  the  fcrotum,  the 
whole  rtiould  hz  firmly  fupported,  either  with  a  well 
adapted  fufpenfory,  or  a  proper  application  oi  the  T 
bandage.* 

Tile  patient  being  in  this  flate  laid  in  bed,  all  kind 
of  uneafinefs  is,  in  a  few  minutes,  commonly  gone, 
and  he  goes  about  his  ordinary  bufmefs  without  inter- 
ruption. In  a  few  infiances,  however,  it  has  happen- 
ed, either  from  the  external  air  finding  accefs  to  the 
tefticle,  or  from  the  fore  produced  by  the  trocar  be- 
coming inflamed,  that  the  whole  body  of  the  tefticle 
has  been  feized  with  inflammation,  by  which  a  radical 
cure  of  the  difeafe  has  been  obtained.  This,  howev- 
er, is  a  rare  occurrence,  and  hardly  to  be  looked  for. 

About  four  years  ago,  the  public  was  favoured  with 
fome  obfervations  on  this  dii'eafe  by  Mr.  Keate,  of 
London,  in  which  fome  cafes  are  related  of  hydrocele 
being  cured  by  the  external  ufe  of  a  ftimulating  ap- 
plication, a  ftrong  folution  of  fal  ammoniac  in  vinegar 
and  fpirit  of  wine.  The  following  is  the  formula  em- 
ployed by  Mr.  Keate  : 

§,.  Sal.  ammoniac,  in  pulv.  trit.  ^  i. 
Acet.  fpirit.  vin.  red.  fing.  ^  iv. 

A  quantity  of  foft  old  hnen,  well  moiftened  in  this, 
is  defired  to  be  folded  round  the  fcrotum,  to  be  fup- 
ported with  a  fufpenfory  bag,  and  renewed  three  times 
a  day  :  but,  although  I  have  given  this  method  a  fair 
trial  in  upwards  of  twenty  cafes,  in  fome  while  the 
cyft  remained  diftended,  and  in  others  immediately 
after  the  water  was  drawn  off,  I  have  not  been  fo  for- 
tunate as  to  fucceed.     In  fome,  the  application  of  dif- 

•  Some  very  judicious  remarks,  on  the  importance  of  a  due  compref- 
fion  in  fuch  cafes,  may  be  met  with  in  remarks  upon  this  fubje<St,  ia  the 
works  of  the  late  Dr.  Monro. 


58  On  the  Hydrocele,  Chap.  XXIV. 

ferent  flimulants  and  aflringents  after  the  operation  of 
tapping,  has  appeared  to  prevent  the  coUedlion  from 
returning  fo  quickly  as  it  otherwife  might  have  done  ; 
but  even  this  has  not  been  frequent,  and  in  no  in- 
Itance,  in  the  courfe  of  my  obfervation,  has  it  produ- 
ced a  cure. 

With  the  fame  view,  1  have  employed  a  variety  of 
flimulants  and  aftringents,  fuch  as  volatile  liniment, 
prepared  with  fix  parts  of  oil,  one  of  camphor,  and 
one  of  fpirit  of  hartihorn  ;  tinfture  of  cantharides ; 
the  fleams  of  vinegar  :  poultices  of  vinegar  and  crum 
of  bread  ;  and  compreiles  of  linen,  foaked  in  brandy  : 
and  the  practice  being  neither  attended  with  difficulty 
or  hazard,  I  mean  to  continue  it  till  farther  experi- 
ence fliows,  whether  it  fhould  be  retained  or  not. 
That  it  will  often  prove  fuccefsful  in  removing  a  hy- 
drocele, by  promoting  the  abforption  of  the  fluid  con- 
tained in  the  tunica  vaginalis,  is  fcarcely  to  be  ex- 
pedted  ;  but  we  may  rcafonably  fuppofe,  that  flimu- 
lating  applications,  capable  of  exciting  inflammation 
in  the  tefles,  may  accomplifli  a  cure,  after  the  water 
has  been  drawn  off  with  a  trocar. 

Drawing  ofi'  the  water  with  a  trocar  is  an  operation 
eafily  performed,  and  it  very  feldom  does  harm  ;  but 
when  not  done  with  caution,  efpecially  when  the  pa- 
tient is  allowed  to  walk  or  ride  foon  after  the  water  is 
taken  away,  it  fometimes  ends  in  very  troublefome 
fymptoms.  If  the  habit  of  body  is  bad,  this  will  hap- 
pen with  whatever  attention  it  may  be  done.  Of  this 
every  practitioner  may  have  met  with  inflances  ;  and 
two  are  related  by  Mr.  Pott,  one  of  which,  terminated 
fatally,  and  gangrene  enfued  in  the  other,  which,  in  a 
few  days,  deflroyed  not  only  a  good  deal  of  the  fcro- 
tum,  but  even  a  confiderable  portion  of  the  tunica  va- 
ginahs.*  Both  of  thefe,  indeed,  occurred  in  very 
unhealthy  conflitutions  ;  but  it  is  proper  to  have  it 
known,  that  even  this  operation  may,  in  certain  hab- 

•  Cafes  ixj.  and  xxii.  Trcatife  on  the  Hydrocele. 


Sccl.  III.  On  the  Hydrocele.  59 

its  of  body,  be  produdive  of  very  diftrefsful  confc- 
quences. 

Drawing  the  water  off  in  this  manner,  in  order  to 
give  rehef  from  the  bulk  and  weight  which  it  produ- 
ced, would  probably  be  the  firfl  idea  that  occurred  to 
praclitioners  in  the  treatment  of  hydrocele  ;  but  be- 
ing found  inadequate  to  the  complete  removal  of  the 
difeafe,  various  other  methods  were  afterwards  intro- 
duced. The  actual  cautery,  and  the  ligature,  were 
both  propofed  as  means  of  preventing  farther  defcents 
of  water  from  the  abdomen,  which,  in  former  times, 
was  confidered  as  the  origin  of  this  difeafe.  Celfus 
advifes  the  cyft  of  a  hydrocele  to  be  cut  away,  and 
many  of  his  followers  do  the  fame.  Tents,  both  folid 
and  hollow,  were  afterwards  employed ;  as  was  like- 
wife  the  ufe  of  the  feton,  which  we  find  recommended 
by  Fabricius  ab  Aquapendente,  and  other  writers, 
even  of  a  more  early  period.  Various  applications, 
of  the  cauftic  kind,  have  at  different  times  been  in 
vogue  :  injecling  wine,  diluted  ardent  fpirits,  and  oth- 
er irritating  liquids,  into  an  opening  in  the  vaginal 
coat,  has  been  propofed,  as  a  means  of  inducing  a  de- 
gree of  inflammation  fufficient  for  effeiSting  a  radical 
cure  ;  and  a  funple  incifion  of  the  cyft  containing  the 
water,  has  been  praclifed  for  the  fame  purpofe.  Thefe 
are  the  means  which,  at  different  periods,  have  been 
employed  for  the  cure  of  hydrocele.  Ancient  pra6ti- 
tioners  feem  to  have  been  acquainted  vv^ith  all  of  them ; 
but  having  very  inaccurate  ideas  of  the  anatomy  of 
the  parts  concerned,  they  could  not  have  any  fixed  or 
clear  opinion  of  the  manner  in  which  any  of  their  re- 
medies afted  in  eifecling  a  cure.  In  confcquence  of 
this,  they  were  applied  at  random  ;  and  none  of  them 
proving  in  general  fuccefsful,  the  ignorance  they  la- 
boured under  in  the  theory  of  the  difeafe,  made  theni 
frequently  propofe  varieties  in  the  method  of  cure. 

The  moderns  pofiefs  one  important  advantage  over 
the  ancients,  from  knowing  that  the  water  in  hydro- 
cele is  contained  in  a  particular  cyft  having  no  imme- 


6o  On  the  Hydrocele.  Chap.  XXIV. 

diate  communication  with  any  other  part  or  cavity  of 
the  body,  and  from  finding  that  this  difeafe  refembles, 
in  many  refpeds,  other  encylled  tumors,  with  the 
means  of  curing  which  they  are  well  acquainted. 

Both  in  encyfled  tumors  and  hydrocele,  the  con- 
tents of  the  fwelling  are  fecluded  from  the  external 
air.  Neither  of  them  have  any  communication  with 
any  other  part  of  the  body  ;  and,  although  the  bag 
containing  the  matter  of  an  encylled  tumor,  is  in  fome 
meafure,  a  new  formation,  yet  in  many  inftances,  it  is 
found  to  be  equally  firm  and  elaftic  with  the  tunica 
vaginalis  teflis. 

In  the  treatment  of  encyfled  tumors,  pra£litioners 
are  now  agreed,  that  befides  evacuating  the  matter, 
means  mud  be  employed  for  deftroying  the  cavity 
which  contained  it,  otherwife  it  will  colled  again.  To 
accom.phili  this,  different  methods  have  been  propof- 
ed  ;  fome  with  a  viev/  to  deftroy  entirely  the  cyft 
which  contained  the  matter,  and  others,  as  it  is  faid, 
to  fill  up  the  cavity,  by  a  formation  of  new  parts. 

But  we  know,  that  unlefs  the  coats  of  a  cyfl  are 
much  extended,  hard,  or  greatly  thickened  indeed,  no 
part  of  it  fhould  be  removed.  It  is  alfo  knovra,  that 
to  fill  up  the  cavities  of  tumors  with  a  formation  of 
new  parts,  is  a  mere  imaginary  thing,  being  what 
neither  nature  or  art  can  do  to  any  extent ;  and  we 
likev/ife  know,  that  the  cavity  of  every  tumor  may  be 
more  eileciually  deftroyed  by  producing  an  adhefioii 
of  its  fides,  than  by  any  other  means. 

Parts  of  the  human  body,  in  a  ftate  of  inflamma- 
tion, very  readily  adhere  together.  So  eafily  indeed 
do  they  do  fo,  tha.t  fome  art  is  required  to  prevent  the 
adhefion  of  contiguous  inflamed  parts,  of  which  every 
practitioner  muit  have  met  with  examples.  Hence, 
abfceffes  and  encyfled  tumors  are  more  eafily  cured 
by  exciting  inflammation  over  their  internal  furfaces, 
after  their  contents  are  evacuated,  than  by  any  other 
means  ;  and,  in  like  manner,  it  is  now  known,  that 
the  hydrocele  of  the  tunica  vaginalis  may  be  treated 


Se6l.  III.  On  the  Hydrcccle.  6t 

upon  the  fame  principles,  and  with  the  fame  general 
efFefts. 

This  is  the  mod  fimple  idea  that  can  be  given  of 
the  practice  that  fhould  be  kept  in  view  in  the  cure  of 
hydrocele  ;  and  I  hope  it  will  ferve  to  render  it  clear 
and  intelligible. 

The  intention,  then,  of  every  means  now  in  ufe  for 
the  radical  cure  of  this  fpecies  of  hydrocele,  is,  to  in- 
duce fuch  a  degree  of  inflammation  on  the  parts  in 
which  it  is  feated,  as  may  tend  to  obliterate  entirely 
the  cavity  of  the  tunica  vaginalis,  by  making  it  ad- 
here firmly  to  the  tunica  albuginea,  the  furface  of  the 
teflicle. 

Some  individuals,  indeed,  flill  proceed  upon  the 
fuppofition  of  a  total  deflrudtion  of  the  fac  being  ne- 
celVary  for  a  complete  cure  ;  but  extenfive  experience 
now  makes  it  evident  that  this  is  not  the  cafe.  When 
the  fac  has  become  unufually  thick  or  hard,  it  proves 
fometimes  ufeful  to  remove  thofe  parts  of  it  that  are 
particularly  difcafed  ;  and  when  it  has  been  diftended 
to  fuch  a  degree  as  entirely  to  have  loft  its  tone,  re- 
moving a  part  of  it  may  forv/ard  the  cure,  by  allow- 
ing the  fcrotum  to  contraft  more  readily  ;  but  it  hap- 
pens fo  feldom  from  any  of  thefe  caufes,  that  I  have 
only  met  with  a  very  few  inftances,  in  which  it  ap- 
peared neceflary  to  remove  any  part  of  it.  A  cure 
may  indeed  be  obtained  of  this  variety  of  hydrocele, 
by  removing  the  fac  entirely  ;  for  the  contiguous  parts 
from  which  it  is  cut  away,  readily  adhere  together,  fo 
as  to  deftroy  the  cavity  in  which  the  fluid  was  con- 
tained ;  but  what  I  wifli  to  have  underftocd,  is,  that 
we  are  not  to  confidcr  it  as  neceflary,  as  the  fame  end 
may  be  obtained  by  much  more  lenient  meafures. 

I  fnall  now  proceed  to  fpeak  more  particularly  of 
the  fevcral  means  at  prefent  moft  frequently  employ- 
ed by  praftitioners  for  eifedting  a  cure,  and  fhall  treat 
moft  minutely  of  thofc  now  in  general  ufe.  Thefe 
arc,  excifion  of  the  tunica  vaginalis;  the  application 
of  cauftic  J  the  ufe  of  a  fcton  j  a  ftmple  incifion  of 


63  Onihe  Hydrocele.  Chap.  XXIV/ 

the  fac ;  and  injeding  wine  and  other  acrid  liquors 
into  the  tunica  vaginalis,  after  drawing  off  the  Huid 
which  it  contained. 

The  method  of  cure,  by  removing  the  vaginal  coat, 
which  was  well  known  to  the  ancients,  had  nearly 
fallen  into  difufe,  when  it  was  revived  by  the  late  Mr. 
Douglas  of  London  ;  and  by  a  few  practitioners  it  is 
Hill  continued.  The  method  of  doing  it  is,  firfl:  to 
diffeck  out  an  oval  piece  of  the  fcrotum,  which  Mr. 
Douglas  confidcrs  as  always  neceffary  ;  and  having 
then  laid  the  vaginal  coat  open,  to  cut  it  away  by  dif- 
ferent fnips  with  fciffars.  But,  whoever  may  contin- 
ue to  think  favourably  of  the  excifion  of  the  fac,  will 
find,  that  it  may  be  more  eafily  done  with  a  fcalpel 
than  with  fciffars" ;  and  it  can  feldom  or  never  be  ne- 
celTary  to  remove  any  portion  of  the  fcrotum; 

As  much  danger  might  enfue  from  the  incifion  be- 
ing carried  too  near  to  the  tefticle,  all  the  pofterior 
part  of  the  fac,  or  that  part  of  it  by  which  the  teflicle 
is  connected  to  the  fcrotum,  fliould  be  allowed  to  re- 
main. On  the  fac  being  removed,  the  parts  mufl  be 
dreffed,  and  treated  in  every  other  refpecl  in  the  fame 
manner  as  in  the  operation  with  the  fimple  incifion  to 
be  hereafter  defcribed. 

The  cure  by  caufiic  has  commonly  been  conducted 
as  follows  :  the  fcrotum  being  fiiaved,  a  piece  of  com- 
mon pafte  cauitic,  properly  fecured  with  adhefive  plaf- 
ter,  is  applied,  of  about  a  ringer's  breadth,  the  whole 
length  of  the  tumor  ;  and  if,  on  removing  the  cauflic, 
it  has  not  penetrated  the  tunica  vaginalis,  an  opening 
is  made  in  it  wdth  a  fcalpel,  fo  as  to  evacuate  the  con- 
tents, lay  bare  the  tefticle,  and  admit  of  proper  drefl- 
ings. 

But  Mr.  Elfe,  one  of  the  latefi:  writers  in  favour  of 
the  method  of  cure  by  cauftic,  fays,  that  there  is  no 
neceflity  for  fuch  an  extcnfive  application  of  cauflic 
as  many  have  recommended  ;  that  an  elchar,  of  the 
fize  of  a  fliilling,  is  fufficient ;  that  this  may  be  always 
fully  obtained  by  the  application  of  cauftic  pafte,  of 


Sea.  III.  0?i  the  Hydrocele,  6^ 

the  fize  of  a  fixpence,  which  he  dire£ls  to  be  laid  up- 
on the  anterior  and  under  point  of  the  fcrotuin,  and 
to  be  properly  fecured  by  adhefive  plafter,  in  order  to 
prevent  it  from  fpreading.* 

The  cauflic  commonly  produces  all  its  effects  in 
the  fpace  of  five  or  fix  hours,  and  may  then  be  re- 
moved. At  this  time,  digeftives,  or  an  emollient  poul- 
tice, muff  be  applied  over  the  fcrotum  j  and  the  whole 
properly  fufpended  with  a  bandage. 

Inflammation,  Mr.  Elfe  obferves,  is  foon  induced 
over  the  whole  tunica  vaginalis  ;  and  the  febrile  fymp- 
toms  that  fuccecd,  he  advifes  to  be  kept  moderate  by 
bloodletting,  injections,  emollient  poultices,  and  a  low 
regimen.  In  a  few  days,  the  efchar  of  the  fcrotum 
feparates,  and  comes  away  ;  and,  in  a  gradual  man- 
ner, in  the  courfe  of  four,  five,  or  fix  weeks,  the  whole 
tunica  vaginahs  comes  off,  when  the  wound,  for  the 
mofl  part,  foon  heals,  and  a  complete  cure  is  obtained. 

In  the  cure  of  the  hydrocele  by  the  feton,  the  fol- 
lowing is  the  method  of  applying  it,  as  ad\ifed  by  the 
late  Mr.  Pott,  who  wrote  a  full  and  ingenious  treatife 
on  the  fubjeft  :  he  ufed  a  trocar  ;  a  filvcr  canula,  five 
inches  in  length,  and  of  fuch  a  diameter  as  to  pafs  ea- 
fdy  through  the  canula  of  the  trocar  ;  and  a  probe, 
fix  inches  and  a  half  long,  having,  at  one  end,  a  fine 
ftcel  trocar  point,  and  at  the  other,  an  eye,  which  car- 
ries a  cord  of  coarfe  white  fewing  filk,  of  fuch  thick- 
nefs  as  to  pafs  eafily  through  the  long  canula.  With 
the  trocar  the  inferior  and  anterior  point  of  the  tumor 
is  to  be  pierced  ;  and,  as  foon  as  the  perforator  is 
withdrawn,  and  the  water  difcharged,  the  feton  canu- 
la is  paffed  through  that  of  the  trocar,  till  it  reaches 
the  upper  part  of  the  tunica  vaginalis,  and  is  felt  in 
the  fuperior  part  of  the  fcrotum.  This  being  done, 
the  probe,  armed  with  its  feton,  is  to  be  conveyed 
through  the  latter  canula,  the  vaginal  coat  and  tegu- 

*  vide  An  EfTay  on  the  cure  of  the  hydrocele  of  the  tunica  vaginalis 
teflie,  by  Mr.  Elfc,  ad  edit.  p.  33. 


64  On  the  Hydrocele.  Chap.  XXIV, 

inents  to  be  pierced  with  the  point  of  it,  and  the  feton. 
to  be  drawn  through  the  canula,  till  a  fufficient  quan- 
tity is  brought  out  at  the  upper  orifice,  when  both 
canulas  are  to  be  withdrawn,  and  the  operation  is  fin- 
ifhed. 

About  the  end  of  the  third  day,  the  parts  begin  ta 
inflame  ;  when  fomentations,  poultices,  a  fufpenfory 
bandage,  a  temperate  regimen,  and  a  lax  belly,  are 
ordered,  to  keep  the  fymptoms  moderate.  As  foon 
as  the  parts  become  eafy,  by  the  inllammation  leflen- 
ing,  which  is  generally  about  the  tenth  or  twelfth  day, 
the  feton  is  begun  to  be  diminifned,  when  fix  or  eight 
threads  are  v/ithdrawn  at  every  drcfcng  ;  the  drefTmgs, 
conliiling  of  nothing  more  than  a  fuperficial  pledget 
en  each  orifice,  and  a  difcutient  cerat.*.,  fuch  as  the  ce- 
ratum  faturninum,  to  cover  the  fcrotum. 

In  the  treatment  of  the  hydrocele  with  a  feton,  I 
fhould  wilh  to  follow  Mr.  Pott's  method,  in  every  cir- 
cumflance  but  the  mode  of  introducing  it,  which  is 
rendered  unneceiTarily  complex,  by  the  number  of  in- 
ftruments  propofed  for  it.  Ir>  Chapter  I.  I  have  de* 
fcribed  the  manner  of  opening  abfccifes  with  a  feton, 
and  the  direciions  then  given  prove  equally  applica- 
ble here. 

Let  an  opening  be  made  with  a  fcalpel,  a  large  lan- 
cet, or  fnarp  pointed  bifloury,  in  the  fuperior  part  of 
the  tumor,  large  enough  to  admit,  with  eafe,  a  cord, 
confiding  of  about  thirty  threads  of  common  white 
fcwing  filk.  A  direflor,  with  an  eye  at  one  end, 
Plate  CXIII.  fig.  3.  in  which  the  cord  is  inferted,  is 
to  be  introduced  at  this  opening  ;  and  its  farther  ex- 
tremity being  carried  down  to  the  m.qft  depending  part 
of  the  tumor,  an  opening  is  there  to  be  made,  half  art 
inch  in  length,  by  cutting  on  the  director  with  the  bif- 
toury.  The  diredor  being  now  drawn  down  till  a 
fufficient  quantity  of  filk  is  left  hanging  out  below,  the 
operation  is  in  this  manner  finifhed.  In  every  other 
refpeft,  the  management  of  the  feton  fliouid  be  the 
fame  with  the  method  defcribed  above  from  Mr.  Pott ; 


1 


Se£t.  III.  Un  the  Hydrocele.  6$ 

or,  inftead  of  introducing  the  cord  with  a  dire£lor,  it 
may  be  done  with  a  filver  canula  and  perforator,  re- 
prefented  in  Plate  CXIII.  fig.  i.  2.  and  4. 

By  making  the  firfl:  opening  in  the  upper  part  of 
the  tumor,  the  inflrument  conducing  the  feton  is  more 
eafily  introduced  along  the  courie  of  it,  than  when  the 
firfl  opening  is  made  below ;  for,  in  this  cafe,  the  tu- 
mor remains  diflended  to  the  laft  :  whereas,  when  op- 
ened below,  the  contents  rufli  out  immediately  ;  and 
the  vaginal  coat  collapfes  fo  much  about  the  teflicle, 
that  I  have  known  it  diflicult  to  get  the  inftrument 
iufinuated  between  them,  by  which  the  tefl:is  has,  in 
dilferent  inftances,  been  injured  ;  and,  by  making  the 
under  opening  half  an  inch  long,  any  matter  which 
forms  in  the  courfe  of  the  cure  is  eafily  and  readily 
difcharged  :  whereas,  in  Mr.  Pott's  method  of  opera- 
ting, where  the  opening  is  not  larger  than  the  fize  of 
the  trocar,  as  this  is  completely  filled  by  the  cord,  the 
matter  is  thereby  allowed  to  colleft ;  an  incifion  be- 
comes neceflaiy,  to  difcharge  it ;  and  thus  the  patient 
is  expofed  to  pain  and  difappointment,  as  I  have  feen. 
in  various  inflances,  where  the  precaution  I  have  men- 
tioned has  been  omitted,  of  making  the  opening  at  the 
moft  depending  part  of  the  tumor  fufficiently  large  for 
difcharging  any  matter  that  may  form. 

Before  entering  farther  into  the  confideratlon  of  the 
method  of  cure  by  the  feton,  I  fhall  proceed  to  defcribe 
the  operation  for  a  radical  cure,  by  incifion. 

The  patient  being  laid  upon  a  table  of  convenient 
height,  and  properly  fecured  by  afliflants,  with  the 
fcrotum  lying  nearly  on  the  edge  of  the  table,  the  op- 
erator, with  one  hand,  fliould  grafp  the  tumor  behind, 
fo  as  to  hold  it  firm,  and  make  it  fomewhat  tenfe  on 
the  anterior  part  of  it :  with  a  round  edged  fcalpel  in 
the  other,  he  fhould  now  divide  the  external  teguments 
by  one  continued  incifion  from  the  upper  end  of  the 
tumor,  all  along  its  anterior  furface,  down  to  the  moft 
depending  point  of  it. 

Vol.  III.  F 


66  On  the  Hydrocele.  Chap.  XXIV. 

If  the  mclfion  has  been  properly  made,  the  divided 
fcrotum  will  retract,  and  the  tunica  vaginalis  will  be 
laid  bare,  for  the  breadth  of  about  half  an  inch  over 
its  whole  length.  An  opening  is  now  to  be  made  in 
the  vaginal  coat,  juft  at  the  upper  end  of  the  tumor, 
where  the  firll  incifion  commenced,  and  it  may  be 
done  either  with  a  lancet,  or  fharp  pointed  bifloury, 
or  a  fcalpel.  This  opening  (hould  be  of  fuch  a  fize, 
as  freely  to  receive  the  finger  of  the  operator  ;  which, 
being  inferted,  a  probe  pointed  billoury  is  to  be  con- 
duced upon  it,  and  the  fac  divided  to  the  very  bot- 
tom, directly  in  the  courfe  of  the  firft  incifion.  By 
the  previous  divifion,  of  the  fkin,  with  the  fcalpel  in- 
flead  of  the  bifloury,  the  operation  is  done  with  more 
accuracy,  and  lefs  pain  ;  for  the  fcalpel,  from  its  con- 
vexity, admits  of  a  finer  edge  than  an  inflrument  of 
any  other  form  is  capable  of  receiving,  and  hence  it 
cuts  with  more  eafe. 

By  making  the  incifion  of  the  teguments  and  tuni- 
ca vaginalis  together,  as  in  fome  inftances  I  have  feen 
done,  the  operation  may  be  fomewhat  fliortened  ;  but 
the  time  gained  by  it  is  not  more  than  a  fecond  or 
two,  while  the  incifion  is  apt  to  be  ragged  and  une- 
qual :  for,  when  done  in  this  manner,  particularly  if 
the  tunica  vaginalis  is  firft  opened  in  the  mofl  depend- 
ing p  Eitof  it,  as  fome  have  advifed,  the  parts  cannot 
be  kept  fufficiently  tenfe  for  completing  the  incifion. 

I  have  defired,  that  the  firfl  opening  in  the  vaginal 
coat  may  be  fo  large,  as  eafily  to  receive  the  finger  of 
the  operator,  which  ought  to  be  pufhed  in  behind  the 
biftoury,  without  withdrawing  the  inflrument,  as  is 
commonly  done.  In  this  manner,  we  fhorten  the  op- 
eration, and,  by  giving  a  free  vent  to  the  fluid  contain- 
ed in  the  fac,  we  prevent  it  from  fpreading  and  form- 
ing vefications  in  the  cellular  fubflance  of  the  vaginal 
coat,  and  contiguous  part,  as  it  is  apt  to  do  when  the 
opening  in  the  fac  is  too  fmall.  By  making  the  firfl 
opening  in  the  upper  end  of  the  fac,  much  trouble  and 
inconvenience  is  prevented,  which  always  occur  from 


Sed.  III.  On  the  Hydrocele.  6j 

making  It  below.  For,  as  I  have  before  remarked, 
when  the  tumor  is  firfl  opened  below,  the  water  is  in- 
ftantly  difcharged  ;  and,  as  this  is  followed  by  an  im- 
mediate collapfe  of  the  tunica  vaginalis,  the  direftion 
in  which  it  Ihould  be  cut  is  not  afterwards  eafily  dif- 
covered  ;  whereas,  by  making  the  firft  opening  above, 
as  the  water  is  thereby  gradually  emptied  on  the  open- 
ing being  carried  downwards,  the  vaginal  coat  contin- 
ues diflended  at  the  bottom,  till  the  whole  is  finilhed. 

With  a  view  to  fave  fome  pain  to  the  patient,  the 
late  Mr.  fTunter  advifed  the  incifion,  both  of  the  fcro- 
tum  and  tunica  vaginalis,  to  be  only  two-thirds  of  the 
length  of  the  tumor ;  and  others  have  thought  even 
that  one  half  of  this  is  fufficient.  But  the  difference 
of  pain  between  incifions  of  thefe  ditlerent  lengths  is 
inconfiderable,  and  not  to  be  regarded  when  compar- 
ed with  the  effects  that  refult  from  them.  When  the 
incifion  is  carried  the  full  length  of  the  tumor,  the 
operation  fucceeds  in  every  inflance,  if  the  fubfequent 
part  of  the  treatment  meets  with  due  attention  ;  where- 
as 1  have  known  various  inftances  of  thefe  partial 
openings  being  followed  with  a  return  of  the  difeafe. 

It  is  particularly  proper  to  carry  the  incifion  of  the 
tunica  vaginalis,  down  to  the  moft  depending  point  of 
the  tumor ;  otherwife  the  contents  of  the  fac  will  not 
be  completely  difcharged,  while  room  will  be  given 
for  collections  of  matter  during  the  cure.  It  is  alfo 
proper  to  remark,  that,  in  making  this  incifion  of  the 
fac,  it  ought  to  terminate  at  fome  diflance  from  the 
teftis  ;  for  I  have,  in  different  inftances,  obferved, 
where  the  vaginal  coat  has  been  cut  near  to  the  tefti- 
cle,  that  the  inflammation  was  particularly  fevere. 

The  incifion  being  completed,  the  tefticlc  covered 
with  its  tunica  albugina,  is  brought  fully  in  view.  In 
fome  inftances,  the  teftis  protrudes  from  the  furround- 
ing  parts  ;  in  which  cafe,  it  fnould  be  immediately  re- 
placed, and  covered  as  quickly  as  poffiblc  from  the 
air ;  and  if  no  part  of  the  tunica  vaginalis  is  to  be  re- 


68  On  the  Hydrocele.  Chap.  XXIV. 

moved,  the  drefllng  may  be  finiflitd  directly  on  the 
fac  being  opened. 

Unlefs  the  fac  is  difeafed,  or  fo  much  diftended  as 
entirely  to  have  loft  its  tone,  no  part  of  it,  as  I  have 
obferved  above,  fliould  be  removed :  but  when  har- 
dened to  the  firmnefs  of  cartilage,  as  I  Iiave  more  than 
once  feen,  as,  in  this  ftate,  it  is  apt  to  excite  pain 
when  applied  to  the  tender  furface  of  the  teflis,  it 
ought  undoubtedly  to  be  removed  ;  and  as,  in  this 
ftate,  it  commonly  feparates  with  eafe  from  the  fur- 
rounding  cellular  fubftance,  it  is  eafily  and  quickly 
cut  away  with  a  fcalpel  or  biftoury.  The  removal  of 
any  portion  of  the  fac  from  the  mere  enlargement  of 
the  tumor,  can  feldom  be  neceifary  ;  not  once  in  fifty 
inftances. 

Hitherto  I  have  been  fuppofmg  that  the  difeafe  is 
confined  to  one  fide  of  the  fcrotum  ;  but,  in  fome  in- 
ftances, as  I  have  remarked  above,  we  meet  with  a 
hydrocele  in  both  fides  at  once.  In  this  cafe,  the 
common  practice  is,  to  do  the  operation  twice  in  all 
its  parts,  both  in  the  fcrotum  and  tunica  vaginaHs,  by 
laying  each  collection  open,  from  top  to  bottom,  by 
a  double  incifion.  Some  advife  both  operations  to  be 
done  at  the  fame  time  ;  but,  in  general,  practitioners 
are  afraid  of  too  much  inflammation  being  induced 
by  this  ;  fo  that  one  fide  is  commonly  allowed  to  heal 
before  the  other  is  opened.  In  this  m.anner,  the  pa- 
tient is  expofed  to  delay,  uncertainty,  and  to  the  con- 
finement arifing  from  two  operations. 

This,  however,  is  not  neceffary,  as  the  operation 
may  be  done  on  both  fides  at  once,  v/ith  little  more 
pain,  and,  fo  far  as  I  have  feen,  with  no  more  hazard, 
than  in  the  ufual  method  of  doing  them  feparately. 
The  method  in  which  I  have  done  it  is  this : 

After  finifliing  the  operation  on  one  fide,  an  open- 
ing is  made  into  the  vaginal  coat  of  the  oppofite  tefti- 
cle,  at  the  upper  end  of  it,  through  the  feptum  fcro- 
ti ;  and  the  incifion  being  carried  down  to  the  bottom 
of  the  tumor,  the  cyft  is  thus  equally  well  laid  open. 


Sed.  III.  On  the  Hydrocele.  6g 

the  ferum  is  as  completely  difcharged,  and  the  difeafe 
is  not  more  liable  to  return,  than  by  doing  the  opera- 
tion in  the  ufual  manner,  and  at  different  times. 

Whether  the  hydrocele  is  double,  or  confined  to 
one  fide,  as  foon  as  the  incifion  is  finifhed,  if  the  tef- 
tis  is  found,  the  wound  (hould  be  quickly  drelVed  ; 
and,  I  think  it  right  to  obferve,  tliat,  on  the  manner 
in  which  this  is  done,  much  of  the  fuccefs  ot  the  ope- 
ration at  all  times  depends,  more  indeed  than  is  com- 
monly imagined. 

If  the  vaginal  coat  is  merely  wrapped  about  the  tef- 
ticle,  without  the  interpofition  of  dreflings,  or,  if  the 
divided  fides  of  it  are  immediately  united  with  futures, 
as  fome  have  advlfed,  partial  adhefions  are  apt  to  take 
place,  before  a  degree  of  inflammation  is  produced 
over  the  whole,  fufiicient  for  rendering  the  cure  com-r 
plete.  In  this  manner,  cavities  are  left,  which  either 
fill  with  pus  during  the  cure,  and  require  to  be  laid 
open,  or  they  afterwards  give  rife  to  colledions  of  fe- 
rum, and  thus  occafion  a  return  of  the  difeafe,  differ- 
ent inftances  of  which  have  fallen  within  my  obferva- 
tion.  And,  again,  the  pracHiice  of  fluffing  the  cavity 
of  the  fore  with  dreflings,  is  alfo  a  frequent  caufe  of 
mifchief.  By  rubbing,  or  prefTmg  upon  the  furface 
of  the  teflis,  fuch  a  degree  of  inflammation  is  fome- 
times  induced,  as  excites  much  pain,  inflammation, 
and  fever.  But  this  is  almofl  always  the  fault  of  the 
operator ;  for,  in  a  great  proportion  of  cafes,  if  the 
dreflings  are  properly  managed,  no  violent  fymptoms 
ever  occur. 

After  having  tried  various  ways  of  drefTmg  the 
parts,  the  method  I  have  now  long  purfued,  and  which 
in  no  inflance  I  have  found  to  fail,  is  this  :  the  tefli- 
cle  being  properly  placed  in  the  newly  divided  fac, 
two  pieces  of  foft  old  linen,  exactly  the  length  of  the 
cut,  previoufly  dipped  in  a  linament  of  wax  and  oil, 
are,  by  the  help  of  a  probe,  inferted  to  the  bottom  of 
the  fac,  one  on  each  fide  of  the  tefticle,  between  it 
and  the  vaginal  coat,  care  being  taken  to  leave  a  fuf-. 


70  On  the  Hydrocele.  Chap.  XXIV. 

ficlent  quantity  of  each  pledget  hanging  out  of  the 
wound,  to  admit  of  its  being  eafily  withdrawn  at  the 
firft  dreiling ;  otherwife,  if  the  fwelHng,  which  after- 
wards takes  place,  fliall  be  confiderable,  they  may,  for 
fome  days,  be  entirely  covered,  and  even  at  lall  re- 
moved with  difficulty,  as  I  have  feen  in  different  in- 
ftances  where  this  piece  of  attention  has  been  omitted. 

If  the  tefticle  has  pufhed  forward,  and  is  with  diffi- 
culty retained  in  its  fituation,  as  it  will  be  apt  to  flip 
out  between  the  lips  of  the  wound  between  one  dreff- 
ing  and  another,  no  means  fhould  be  omitted  that  can 
with  fafety  be  employed  for  preventing  it,  as  it  cannot 
afterwards  be  fo  eafily  replaced  ;  and,  from  want  of 
attention  to  this,  I  have  known  the  teflicle  entirely 
extruded  from  the  fcrotum,  and  in  one  inftance,  from 
fufficient  pains  not  being  taken  to  replace  it,  the  cure 
was  completed  with  the  teflis  in  this  fituation  ;  when, 
Inflead  of  being  covered  with  the  vaginal  coat  and 
fcrotum,  it  was  covered  with  fcarf-lkin  only. 

The  beft  method  of  preventing  fuch  a  misfortune, 
is,  to  draw  the  edges  of  the  divided  tunica  vaginalis 
and  fcrotum  nearly  together,  after  the  teflis  has  been 
properly  placed,  and  the  pledgets  of  oiled  linen  in- 
ferted  ;  and,  in  this  fituation,  to  fecure  them,  either 
with  two  or  three  futures,  at  proper  diflances  from 
each  other,  or  with  flips  of  plafter,  fufficiently  adhe- 
five  for  retaining  them. 

This  being  done,  the  whole  fcrotum  is  covered  with 
a  large  pledget  of  faturnine  cerate,  or  common  wax 
ointment,  by  which  the  parts  are  kept  much  more 
foft  and  eafy,  than  when  dreffed,  in  the  ufual  way, 
with  dry  lint,  at  the  fame  time  that  the  dreffings  are 
much  more  eafily  removed.  A  cufhion  of  foft  tow, 
with  a  proper  comprefs,  is  placed  over  the  pledget  of 
ointment,  and  the  whole  are  retained  by  the  T  band- 
age, or  common  fufpenfory  bag.  The  patient  is  now 
carried  to  bed  :  a  quieting  draught  fhould  be  given  ; 
and  he  fhould  be  enjoined  to  remain  as  much  as  pof. 


Sea.  III.  On  the  Hydrocele.  71 

fible  ill  the  fame  poflure ;  for  much  motion  at  this 
period  certainly  does  harm. 

The  intention  of  this  operation  being  to  induce  a 
moderate  degree  of  inflammation  in  the  tunica  vagina- 
lis and  furface  of  the  teflicle,  if  the  pain,  inflamma- 
tion, and  fwelling,  which,  in  fome  degree,  always  fuc- 
ceed,  do  not  run  to  a  great  height,  nothing  is  to  be 
done  for  the  fir  ft  two  or  three  days  after  the  opera- 
tion ;  but,  when  thefe  fymptoms  become  violent,  and 
efpecially  when  much  fever  is  induced,  means  mult 
be  employed  to  leflen  or  remove  them. 

The  remedies  we  chiefly  depend  on,  are  bloodlet- 
ting, gentle  laxatives,  a  low  cooling  diet,  and  warm 
emollient  poultices  and  fomentations  to  the  part,  in 
order  to  forward  a  plentiful  fuppuration,  which  com- 
monly tends  to  moderate  every  bad  fymptom  more 
effeftually  than  any  other  remedy.  By  thefe  means, 
the  inflammation  is  in  general  eafily  kept  within  pro- 
per bounds  ;  but  where  the  mode  of  drefling  I  have 
pointed  out  is  adopted,  they  are  not  often  required. 
In  a  great  number  of  cafes,  in  which  I  have  done  the 
operation  in  this  manner,  I  have  only  once  found  it 
neceflary  to  advife  bloodletting,  and  very  rarely  fo-r 
mentations  or  poultices. 

In  moft  cafes,  the  inflammation  of  the  teflicle  does 
not  rife  higher  than  in  the  fimple  hernia  humoralis 
from  gonorrhoea  j  and  it  gradually  fubfides  as  the  fup- 
puration advances.  The  abatement  of  the  inflamma- 
tion is  alfo  afllfted  by  continuing  a  cool  diet,  the  oc- 
cafional  ufe  of  opiates,  and  keeping  the  belly  open. 

Often  in  two  days,  and  always  by  the  end  of  the 
third,  I  remove  all  the  drefllngs,  except  the  pledgets 
inferted  between  the  teftis  and  tunica  vaginalis.  This 
is  one  important  advantage  we  derive  from  covering 
large  fores  with  pledgets  of  ointment.  The  drefllngs 
are  eafily  removed  at  any  period  ;  fo  that,  without 
waiting  for  a  plentiful  fuppuration,  as  is  commonly 
done,  the  patient  may,  at  any  time,  be  relieved  from 
that  diftrefsful  uneafmefs,  of  which  all  thofe  complaia 


72  On  the  Hydrocele,  Chap.  XXIV. 

in  whom  the  firfl  dre/Tings  are  fevenil  days  in  being 
taken  away.  They  are  always  rendered  ftiiF  and  un- 
comfortable, by  the  blood  dilcharged  upon  them  after 
the  operation  ;  and  the  matter  at  iirft  iecreted  being 
thin  and  acrid,  I  have,  in  various  inflances  feen,  when 
the  dreflings  have  not  been  removed  for  fix  or  feven 
days,  and  in  fome  cafes  even  in  lefs,  that  the  whole 
contiguous  parts  have  been  excoriated  by  the  acrimo- 
ny of  the  matter  alone,  and  by  which  more  uneafinefs 
has  been  induced  during  the  courfe  of  the  cure,  than 
by  any  other  circumflance  connected  with  the  opera- 
tion :  nay,  in  fome,  the  inflammation  induced  in  this 
manner  has  an  obvious  influence  on  that  of  the  tefti- 
cle,  and  tends  to  render  it  much  more  fevere  than  it 
otherwife  would  be. 

On  fome  occafions,  at  the  firfl;  drefling,  and  always 
at  the  fecond  or  third,  the  pledgets  inferted  between 
the  tunica  vaginalis  and  tefl:icle  come  away  ;  and  when- 
ever this  happens,  they  ihould  be  renewed.  It  is  alfo 
proper  to  renew  them  daily,  for  the  firfl:  fourteen  or 
fifteen  days  after  the  operation  ;  not,  however,  of  the 
fame  depth  as  the  firfl:,  as,  during  the  latter  part  of 
the  cure,  it  proves  fuflicient,  if  they  are  merely  infert- 
ed fo  far  as  to  prevent  the  divided  edges  of  the  tunica 
vaginalis  from  adhering  to  the  tefl:icle  before  the  ad- 
hefive  procefs  has  taken  place  in  the  parts  more  deep- 
ly feated.  To  this  point,  I  mufl:  obferve,  the  mofl: 
particular  attention  is  neceffary ;  for,  when  this  mode 
of  operating  fails,  that  is,  when  the  difeafe  returns,  it 
is,  almofl:  in  every  infl:ance,  from  this  precaution  be- 
ing overlooked.  In  my  own  practice,  the  difeafe  has 
not  returned  in  a  fingle  initance  :  but  I  have  met  with 
different  cafes  in  which  it  has  done  fo,  and  in  all  of 
them  from  the  caufe  I  have  mentioned,  to  wit,  the 
divided  edges  of  the  tunica  vaginalis  being  allowed  to 
adhere  to  the  tefl:icle,  before  adhefion  had  taken  place 
between  the  parts  more  deeply  feated. 

In  almofl:  every  circumfl:ance,  the  treatment  of  hy- 
drocele by  this  operation  is  the  fame  with  what  an- 


Bed:.  III.  On  ihe  Hydrocele,  73 

fwers  beft  in  a  common  abfcefs.  After  opening  an 
abfcefs,  if  the  lips  of  the  newly  divided  parts  are  al- 
lowed too  early  to  adhere,  either  to  each  other,  or  to 
the  parts  beneath,  the  operation  will  mod  probably 
fall  to  be  renewed,  as  matter  will  thus  be  allowed  to 
colled,  by  which  the  patient  will  be  nearly  in  the  lame 
fituation  as  before  ;  while  all  manner  of  rifk  of  this  is 
prevented,  by  the  cut  being  kept  open  till  the  fides  of 
the  abfcefs  adhere  to  each  other.  In  like  manner,  we 
never  fail  in  the  cure  of  hvdrocele,  if  the  external  cut 
is  kept  open,  not  till  the  cavity  of  the  tunica  vaginalis 
fills  up  with  granulations,  as  fome  have  imagined  to 
be  necelfary  in  this  mode  of  operating,  but  merely  till 
fuch  a  degree  of  inflammation  is  induced  upon  the 
tefcicle  and  vaginal  coat,  as  terminates  in  their  adhe- 
fion  to  each  other. 

This  idea  of  the  whole  cavity  of  parts  in  this  fitua- 
tion being  to  fill  with  new  granulations,  has  been  held 
out  by  fome  as  an  objedlion  to  this  operation  ;  and  as 
many  believe  that  it  attually  happens,  I  have  judged 
it  proper  to  fpeak  of  it  more  particularly  than  thofe 
will  confider  as  necelfary,  who  have  been  accuflomed 
to  operate  in  this  manner.  No  fuch  procefs  takes 
place  :  inftead  of  it,  the  teflicle  and  vaginal  coat,  foon 
after  the  operation,  become  inflamed  ;  till  the  fixth 
or  fevcnth  day,  the  inflammation  continues  gradually 
to  increafe,  when  the  whole  tumor,  as  1  have  obferv- 
ed  above,  has  acquired  the  ufual  fize  and  appearance 
of  a  common  hernia  humoralis  from  gonorrhoea. 
About  this  period,  the  tunica  vaginalis  is  found  to 
adhere  to  the  tedis,  over  all  the  poflerior  and  lateral 
parts  of  the  tumor,  and  on  the  flips  of  oiled  linen  be- 
ing gradually  leflened,  and  at  laft  withdrawn,  by  the 
fourteenth  or  fifteenth  day,  or  foon  thereafter,  the  ad- 
hefion  becomes  complete  ;  the  tumor  of  the  teflis 
gradually  fubfides,  and  the  fore  produced  by  the  cut, 
and  now  reduced  to  a  line,  heals  in  a  fliorter  or  long- 
er time,  according  to  the  habit  of  body,  age,  and  oth- 
er circumftances  of  the  patient.     In  fome,  the  cure  is 


74  On  the  Hydrocele.  Chap.  XXIV. 

complete  in  three  weeks  ;  I  have  known  it  in  lefs  ; 
while,  in  others,  it  runs  on  to  the  fourth,  fifth,  and 
in  a  few  cafes,  to  the  fixth  week. 

Having  thus  given  an  account  of  the  different  ope- 
rations ufually  employed  for  the  radical  cure  of  the 
hydrocele,  I  fhall  now  make  a  few  obfervations  on  the 
comparative  advantages  of  the  three  lafl,  to  wit,  thofe 
by  cauflic,  the  feton,  and  the  fimple  incifion ;  one  or 
other  of  thefe  being  now  commonly  pradifed  for  the 
removal  of  this  difeafe. 

-  From  the  teftimony  of  many  refpedable  authors 
of  the  efficacy  of  each  of  thefe,  there  is  no  reafon  to 
doubt  that  any  of  them  would,  in  mofl  inflances, 
prove  effectual :  that  the  cauflic,  Vvhen  properly  man- 
aged, will  for  the  mofl  part  fucceed,  we  have  every 
reafon  to  believe ;  and  the  fame  may  be  fafely  affert- 
ed  both  of  the  feton,  and  the  fmiple  incifion ;  but 
every  practitioner  being  apt  to  be  prejudiced  in  favour 
of  a  particular  method,  he  generally  continues  to  prac- 
tife  that  mode,  and  no  other  ;  and  finding  that  it  com- 
monly fucceeds,  he  by  degrees  comes  to  perfuade 
himfelf,  that  other  methods  of  cure,  with  which  he 
has  not  had  fuch  opportunities  of  becoming  acquaint- 
ed, are  liable  to  objections,  which  thofe  who  have 
pra£tifed  them  do  not  find  to  be  the  cafe. 

I  happened  to  attend  the  hofpitals  in  London,  about 
the  time  that  Mr.  Pott's  publication  on  the  feton,  and 
Mr.  Elfe's  treatife  on  the  cure  of  the  hydrocele  by 
cauflic,  were  publifhed  ;  when,  of  courfe,  the  various 
means  of  curing  the  difeafe  were  frequently  the  fub- 
je£t  of  medical  converfation.  I  was  thereby  induced 
to  pay  much  attention  to  the  fubje6t ;  and  having  the 
advantage  of  feeing  the  pradtice  of  different  hofpitals, 
and  not  being  particularly  biaffed  in  favour  of  any 
particular  method,  I  was  thus  furnifhed  with  the  befl 
opportunity  that  could  be  wiflied  for  of  forming  an 
opinion  :  and  the  refult  of  all  the  obfervation  1  was 
either  at  that  time  able  to  make,  or  fmce  that  period, 
both  in  the  hofpital  here,  and  in  private  pradice,  is, 


Sed.  III.  On  the  Hydrocele.  y^ 

that  although  all  the  three  modes  of  operating,  by 
cauftic,  the  feton,  and  fimple  incifion,  are  perhaps 
equally  capable  of  producing  a  radical  cure  ;  yet  that 
of  the  three,  the  latter,  to  wit,  the  mode  by  the  fimple 
incifion,  is  liable  to  feweft  objections,  and  effects  a 
cure  both  with  lead  trouble  to  the  operator,  and  leafl 
rifk  to  the  patient :  and,  of  the  other  two,  the  treat- 
ment by  cauftic  appears  to  me  to  be  the  beft. 

I  have  feen  all  the  three  produce  troublefome  fymp- 
toms,  fuch  as  pain,  and  tenfion  of  the  abdomen,  in- 
flammation, and  fever ;  but,  from  much  obfervation, 
I  can,  without  hefitation  fay,  that  the  feton  is  more 
frequently  productive  of  thefe  than  either  of  the  oth- 
ers ;  nor  need  we  wonder  at  this  being  the  cafe  ;  for 
the  cord  which  is  here  introduced,  lying  in  clofe  con- 
tacl:  with  the  body  of  the  teftis,  muft  neceffarily  occa- 
fion  a  confiderable  and  continued  irritation,  as  long  as 
it  remains  applied  to  it. 

The  feton  is  likewife  attended  with  other  inconve- 
niencies,  to  which  neither  of  the  others,  when  proper- 
Iv  managed,  are  liable.  When  the  inflammation, 
which  fucceeds  to  the  introduction  of  the  cord,  runs 
high,  as  it  frequently  does,  it  ccvmmonly  terminates  in 
fuch  a  plentiful  fuppuration,  that  the  matter  produced 
by  it  cannot  be  readily  difcharged  at  the  opening  made 
for  the  feton.  In  confequence  of  this,  it  finds  accefs 
to  the  neighbouring  parts  ;  and  different  abfcefles  are 
accordingly  formed,  which  muft  all  be  difcharged  by 
as  many  openings.  This  may,  in  part,  be  obviated, 
by  making  the  inferior  opening  of  the  fize  I  have  di- 
rected ;  but,  in  fome  inftances,  I  have  found  even  that 
this  has  not  proved  fufficient,  owing  to  the  opening 
I  being  reduced  in  fize  by  the  fwelling  and  inflamma- 
tion of  the  tumor. 

Another  objection  to  this  operation,  which  I  think 
,  of  importance,  is  this :  it  does  not  admit  of  free  ex- 
I  amination,  either  of  j^Ke  ftate  of  the  tefticle,  or  of  the 
fluid  contained  in  ttie  fac.  I  know  that  in  a  fimple 
uncomplicated  hydrocele,  the  ftate  of  the  tefticle  re- 


jG  On  the  Hydrocele,  Chap.  XXIV. 

quires  no  examination  ;  nor  would  we  think  of  re- 
moving it,  either  on  account  of  a  mere  enlargement, 
or  diminution  of  its  fize,  provided  it  is  not  otherwife 
difeafed.  But  we  know  well,  that  cafes  fometimes 
occur,  which  elude  the  utmoft  (kill  and  penetration  of 
the  furgeon  ;  no  diagnodic  f)-mptoms,  .with  which  we 
are  yet  acquainted,  being  fufficient  to  dire£l  us  with 
ab folate  certainty. 

The  mod  experienced  practitioner  will  admit,  that 
at  times,  he  has  been  miilaken  in  his  opinion  refpe£t- 
ing  the  nature  of  fuch  tumors  ;  a  real  farcocele,  or 
fchirrous  tefticle,  attended  Vvith  fome  effufion  of  a  flu- 
id, being  in  fome  inftances,  miflaken  for  a  pure  un- 
mixed hydrocele  ;  and  vice  verfa,  a  fimple  uncompli- 
cated cafe  of  hydrocele  has  been  miRaken  for,  and 
treated  as  a  fchirrous  tefticle.  Such  occurrences  eve- 
ry praftitioner  muft  have  met  with  -,  and  among  oth- 
ers, who  confefs  their  having  been  deceived  in  this 
manner,  a  very  candid  acknowledgment  is  made  of  it 
by  Mr.  Pott  ;*  and  INIr.  Elfe  takes  notice  of  a  fimilar 
occurrence  in  which  he  was  concerned. 

I  have  been  concerned  in  different  cafes,  where  the 
moft  experienced  furgeons  were  at  a  lofs  to  determine 
the  real  nature  of  the  difeafe ;  that  is,  whether  the 
fweUing  in  the  fcrotum  was  a  hmple  hydrocele  of  the 
vaginal  coat,  or  an  effufion  of  a  fluid  into  that  bag 
produced  by  a  fchirrous  tefticle.  In  all  fuch  cafes  of 
doubt,  the  furgeon  fhould  proceed  as  if  the  tumor 
was  a  real  farcocele.  If,  on  laying  open  the  fwelling, 
the  tefticle  is  found  difeafed,  that  is,  if  it  is  in  fuch  a 
ftate  as  to  require  extirpation,  it  ftiould  be  removed 
immediately  ;  while,  on  the  contrary,  if  it  appears  to 
be  found,  he  will  treat  it  as  a  cafe  of  fnnple  hydrocele. 

♦  Treatife  on  the  Hydrocele,  p.  2S8.  In  this  cafe,  wliicli,  from  evcrj 
tircumrtar.ce,  had  been  confidercd  as  a  farcocele,  the  teflis,  after  being  re- 
moved, was  found  to  be  perfeclly  found,  the  difeafe  being  a  real  hydro- 
cele of  the  tunica  vaginalis.  , 

The  mere  poffibility  of  fuch  an  occurrcn<?'e  with  fuch  an  attentive  ob- 
ferver  as  Mr.  Pott,  ought  to  ferve  as  a  moft  convincing  argument  with 
praiflitioners  of  the  neceflitv  of  proceeding  with  the  utmoft  caution  iu  JiU 
fuch  cafes,  where  there  is  the  It  aft  caufe  for  doubt. 


Sea.  IIL  On  the  Hydrocele.  77 

In  feveral  Inftances  of  this  kind,  where,  by  different 
pradtitioners,  a  mere  colledion  ot  water  was  expected 
without  any  other  alfedion,  the  tefticle  has  been  found 
to  be  fo  much  difeafed,  as  to  render  immediate  extir- 
pation proper.  Now,  if  in  fuch  circumflances  a  cure 
had  been  attempted  by  the  feton,  the  tefticle  would 
have  been  allowed  to  remain  expofed  to  the  irritation 
produced  by  the  cord,  which  probably  would  have  in- 
duced very  troublcfome  and  even  alarming  fyuiptoms  j 
for  we  know  that  every  fymptom  of  a  fchirrous  tumor, 
is  uniformly  rendered  worfe  by  irritation. 

It  has  indeed  been  alleged,  that  the  real  ftate  of  the 
teftis  may  be  always  known,  by  drawing  the  water  off 
from  the  tunica  vaginalis  with  a  trocar  ;  and  this  has 
accordingly  been  recommended  ^.s  a  previous  ftep  to 
the  introdudion  of  the  feton,  with  a  view  to  afcertaiii 
the  flate  of  the  tefticle.  But  it  often  happens,  even 
after  all  the  water  is  drawn  off,  that  the  thicknefs  pro- 
duced by  the  vaginal  coat  and  fcrotum  collapfmg  in 
large  folds  about  the  teftis,  precludes  effedually  every 
accurate  examination  of  this  kind.  Of  this,  where  the 
tumor  has  been  large,  every  praditioner  muft  have 
met  with  inflances  ;  and  we  need  not  be  furprifed  at 
its  being  fo,  when  it  is  known  that  inflances  occur,  in 
which  it  requires  a  good  deal  of  experience  to  deter- 
mine, whether  a  tefticle  is  fo  much  difeafed  as  to  re- 
quire extirpation,  even  when  completely  laid  bare  in 
the  common  operation  for  the  hydrocele.  Of  this  I 
have  known  feveral  cafes  in  which  a  dilFerence  of  opin- 
ion occurred,  even  among  furgeons  of  obfervation ; 
and  among  thefe,  the  mofi  remarkable  happened  in  an 
operation  performed  by  a  late  very  eminent  furgeon. 
The  cafe  was  fuppofed  to  be  a  fchirrous  tefticle  con- 
nected with  the  elfufion  of  a  confiderable  quantity  of 
a  fluid  into  the  tunica  vaginalis.  On  laying  open  the 
tumor,  the  tefticle  was  found  enlarged  and  hard ;  but 
being  neither  painful  nor  unequal  on  the  furface,  the 
operator  thougli":  it  improper  to  remove  it :  the  fur- 
geons prefent  v/erc  of  a  diirerent  opinion  j  but  the 


7?  On  the  Hydrocele.  Chap.  XXIV. 

event  of  the  cafe,  which  was  favourable,  tended  to 
evince  the  fuperior  judgment  of  the  operator,  akhough, 
previous  to  the  operation,  he  had  entertained  a  very 
different  opinion. 

I  have  alfo  obferved  above,  that  when  the  feton  is 
ufed,  the  contents  of  the  cyll  cannot  be  properly  af- 
certained.  It  fometimes  happens,  as  will  be  more  par- 
ticularly noticed  in  the  next  feclion,  that  a  portion  of 
gut  is  contained  in  the  upper  part  of  a  hydrocele.  Of 
this  I  have  met  with  feveral  cafes,  in  fome  of  which 
no  fufpicion  was  entertained  of  it,  till  the  fac  was  laid 
open,  although  in  two  of  them  the  vv-ater  had  previ- 
oufly  been  drawn  off  with  a  trocar. 

In  other  inftances,  the  water  of  a  hvdrocele  is  con- 
tained in  hydatids  ;*  a  circumftance  not  to  be  difcov- 
ered  previous  to  the  opening  of  the  tumor  :  and  as  it 
will  be  readily  admitted  that  the  method  of  cure  by 
feton  is  ill  fuited  for  difcharging  hydatids,  this  of  itfelf 
is  a  material  obje6lion  to  the  practice  ;  fo  that,  al- 
though the  feton,  in  every  other  refpeft  were  equally 
eligible  with  the  fnnple  incifion,  which,  for  the  rea- 
fons  formerly  given,  I  think  it  is  not,  yet  the  three  lafl 
objeclions  that  I  have  adduced  againfl  it,  feem  to  be 
fufficient  reafons  for  fetting  it  afide. 

With  refpect  to  the  mode  of  treatment  with  cauftic, 
I  have  only  to  obferve,  in  addition  to  what  has  already 
been  faid  of  it,  that  where  patients  are  naturally  timid, 
and  do  not  incline  to  fubmit  to  the  operation  by  the 
knife,  this  may  be  put  in  pradice. 

But  the  method  of  cure  by  caufhic  is  hable  to  one 
important  objeclion,  which  never  attends  the  cure  by 
incifion,  to  wit,  that  of  being  produftive  of  fmufes, 
and  collections  of  matter,  in  the  fcrotum  and  cellular 
fubflance  connecting  that  bag  to  the  tunica  vaginalis. 
Two  inftances  of  this  I  have  feen,  in  which  it  was  ne- 
ceffary  to  difcharge  collections  of  matter  by  different 

*  Thofe  who  doubt  of  the  cxiftcnce  of  hydatids  iti  c.ifcs  of  hydrocele, 
as  fome  have  done,  will  find  difTcrcirc  inflauccs  of  thcni  recorded  ui  Mor- 
gagni  de  Caufis  ct  Sedibus  Morboruin. 


Sect.  in.  On  the  Hydrocele,  79 

openings  ;  and  a  remarkable  cafe  of  It  is  related  by 
Douglas,  in  which  an  extenfive  incifion  became  ne- 
ceffary  for  removing  the  colledcd  matter.*  For  this 
reafon,  therefore,  and  as  the  method  of  cure  by  inci- 
fion brings  the  ftate  of  the  tefticle  immediately  and 
more  completely  into  view,  and  efpecially  as,  from  all 
the  experience  I  have  had  of  the  two  different  modes 
of  operating,  that  by  incifion  feems  to  produce  the 
lead  troublefome  fymptoms,  I  am  decidedly  of  opin- 
ion that  it  fhould  be  preferred. 

In  points  of  fuch  importance,  no  perfon  fliould  form 
any  opinion  haftily.  Nothing  but  various  opportuni- 
ties of  putting  the  different  operations  in  practice,  can 
enable  any  one  to  judge  of  the  merits  of  each.  Even 
in  the  writings  of  the  late  celebrated  Mr.  Sharpe,  we 
find  a  remarkable  inflance  of  this.  In  his  treatife  on 
the  operations  of  furgery,  he  fpeaks  of  the  radical  cure 
of  hydrocele,  whether  by  cauftic  or  incifion,  or  in 
"whatever  way  it  is  done,  as  a  very  dangerous  opera- 
tion, and  feems  to  think  that  it  will  be  entirely  laid 
afide.f 

At  that  time  it  is  evident  that  Mr.  Sharpens  experi- 
ence in  this  difeafe  was  not  fufficient  to  warrant  a  de- 
cifive  opinion.  It  proved  to  be  contrary  to  the  direct 
experience  of  fome  of  our  belt  furgeons  ;  and  Mr, 
Sharpe  himfelf  feems  afterwards  to  have  been  convinc- 
ed that  his  firft  ideas  of  it  had  been  ill  founded.  J  Still, 
however,  his  firft  opinion  had  much  influence  with  a 
great  proportion  of  furgeons  ;  fo  that,  till  of  late  vears, 
the  radical  cure  of  hydrocele  was  Teldom  attempted 
but  in  large  hofpitals  :  and  when  at  laff:  it  was  found 
that  the  danger  attending  it  was  lefs  than  had  been  re- 
prefented,  (till,  the  terror  induced  by  Mr.  Sharpe's  ac- 
count of  the  mode  of  operating  by  incifion,  was  fuch, 
that  almoll  all  who  wrote  upon  it,  were  afraid  of  ad- 
vifing  it  to  be  fo  generally  performed  as  it  ought  to  be. 

•  p.  105. 

t  Tenth  Edition,  Chap.  IX. 

\  Vide  Critical  Imiuiry,  firft  edition,  p.  86. 


8o  On  the  Hydrcccle.  Chap.  XXIV. 

"When  the  earlier  editions  of  this  work  were  pub- 
lifhed^  although  I  gave  the  fame  opinion  of  this  ope- 
ration that  I  have  now  done,  and  of  the  preference  to 
which  it  appeared  to  be  entitled,  and  although  my  ex- 
perience of  its  utility  and  fafety  had  at  that  time  been 
confiderable,  yet,  finding  it  fpoken  of  with  much  cau- 
tion by  many,  and  among  others  by  Mr.  Pott,  I  did 
not  venture  to  recommend  it  fo  warmly  for  general 
ufe,  as  I  am  now  by  much  additional  experience  ena- 
bled to  do.  Although  I  had  performed  the  operation 
in  a  great  number  of  cafes,  without  lofmg  a  patient, 
yet,  as  in  fome  the  inflammation  came  to  a  confidera- 
ble  height,  I  was  afraid  that  in  others  the  dreadful  ac- 
counts that  were  given  of  it  by  authors  might  occa- 
fionly  be  realized.  This  induced  me  not  only  to  fpeak 
of  it  with  caution,  but  to  endeavour,  if  pofiible,  to  dif- 
cover  the  caufe  of  the  violence  of  this  fymptom  ;  for 
it  obvioufly  appeared,  not  merely  from  my  own  ob- 
fervation,  but  from  all  the  accounts  which  had  been 
given  of  this  operation,  that  the  danger  attending  it 
was  always  in  proportion  to  the  degree  of  inflamma- 
tion ;  and  therefore,  if  this  could  be  rendered  mode- 
rate, that  little  or  perhaps  no  hazard  would  enfue 
from  it. 

i  did  not  find  that  the  length  of  the  incifion  had 
much  influence  ;  for,  whether  it  was  to  the  full  extent 
of  the  tumor,  or  only  to  one-third  of  that  length,  the 
inflammation  appeared  to  be  the  fame.  Some  advan- 
tage indeed  was  derived  from  attending  to  the  direc- 
tion of  the  incifion  ;  for,  wherever  it  was  carried  too 
near  the  teft;icle,  as  is  fometimes  done  at  the  bottom 
of  the  fac,  the  pain  and  inflammation  were  always  fe- 
vere ;  but  the  mofl:  frequent  caufe  of  the  violence  of 
thel'e  fymptoms  appeared  at  lafl:  to  be  the  mode  of 
drelTmg  the  parts  after  the  operation.  It  had  com- 
monly been  the  pradice  to  cram  a  confiderable  quan- 
tity of  drefllngs  into  the  cavity  of  the  tunica  vaginalis  ; 
and,  with  a  view  to  make  ihe  furface  of  the  parts 
flough  quickly  ofi:',  a  procefs  which  at  that  time  was 


Se6l.  III.  On  the  Hydrccele.  8 1 

judged  neceflary  for  the  cure,  red  precipitate  and  oth- 
er irritating  fubftances  were  made  ufe  of  by  many. 
The  impropriety  of  thefe  being  obvious,  dry  Hnt  was, 
by  Mr.  Pott  and  others,  propofed  to  be  ufed  inftead 
of  them.  This  was  an  important  improvement,  and 
it  tended  more  than  any  other  circumftance  to  lefi'en 
the  dread  that  had  been  conceived  of  this  operation 
by  the  writings  of  Mr.  Sharpe.  Still,  however,  the 
inflammation  run  in  many  inftances  too  high  ;  the 
parts  fv;elled  to  a  great  fize,  and  the  patient,  for  the 
lirfl  two  or  three  weeks  of  his  confinement,  was  often 
kept  in  much  diitrefs  and  anxiety. 

Having  frequently  found  that  the  dry  lint  infcrted 
into  the  tunica  vaginalis,  adhered,  at  the  firft  drefling 
of  the  parts,  fo  firmly  to  the  furface  of  the  teftis,  that 
it  could  not  be  withdrawn,  I  at  lad  began  to  conclude 
that  this  might  render  the  inflammation  more  fevere 
than  it  otherwife  would  be  ;  and  it  foon  appeared  that 
my  conjctSlure  was  well  lounded.  For  feveral  years 
pafl  I  have  covered  the  pledgets  applied  to  the  furface 
of  the  teftis,  as  has  been  advhed  above,  either  with 
fine  oil,  or  with  a  thin  linament  of  oil  and  wax,  which 
anfwers  better.  This  gives  much  lufs  pain,  in  the 
firft  inftance,  than  dry  lint,  and  the  pledgets  never  ad- 
here to  the  contiguous  parts  ;  fo  that  they  can  be  as 
eafily  removed  at  the  firft  drefling  of  the  fore,  as  at 
any  future  period  of  the  cure. 

The  effedi:  of  this,  and  of  proceeding  in  the  other 
parts  of  the  treatment,  in  the  manner  I  have  mention- 
ed, has  been,  that  during  all  this  period  the  inflamma- 
tion has  never  gone  farther  than  I  could  have  wiflied 
it  to  do  ;  never  fo  far  as  to  excite  the  leaft  caufe  of 
anxiety.  The  tefticle  fwclls  and  inflames,  but  in  no 
greater  degree  than  is  neccflliry  for  preventing  a  re- 
turn of  the  difeafe.  Of  this  the  cleareft  proof  that  can 
be  given,  is,  that  of  upwards  of  one  hundred  and  fif- 
ty patients  on  whom  I  have  operated  in  this  manner, 
I  have  only  once  found  it  neceflary  to  advife  blood- 

VoL.  III.  G 


82"  On  the  Hydrocele.  Chap.  XXIV. 

letting  ;  and  very  rarely,  as  I  have  formerly  obferved^ 
fomentations  or  poultices* 

I  may  further  mention  one  important  advantage  of 
this  operation,  in  addition  to  what  I  have  faid  of  it, 
that  it  may  be  confidered  as  abfolute  feciirity  againft 
a  return  of  the  difeafe.  I  have  known  indeed  two  in- 
ftances,  and  I  have  heard  of  other  two  in  which  the 
difeafe  returned  after  this  operation  was  performed. 
But  thefe  are  all  the  inflances  I  can  hear  of  its  failure 
in  the  courfe  of  thefe  lad  twenty- five  years  ;  and  in  all 
of  them  the  caufe  was  evidently  traced  to  want  of  that 
perfevering  attention  during  the  cure,  fo  necelfary  for 
the  fuccefs  of  every  operation,  and  particularly  for 
that  of  the  hydrocele. 

That  this  operation  is  not  hazardous,  and  that  it 
may  with  confidence  be  relied  on  againft  future  re- 
turns of  the  difeafe,  I  am  warranted  in  afferting,  not 
only  from  the  univerfal  fuccefs  attending  it  in  this 
country  with  others,  but  from  the  fuccefs  arifing  from 
it  in  my  own  praftice. 

Almofl  every  operation  that  had  been  propofed  for 
the  cure  of  hydrocele,  had,  by  one  or  other  of  our 
furgeons,  got  a  fair  trial ;  to  wit,  that  by  cxcifion  or 
cutting  away  the  greatefl  part  of  the  tunica  vaginalis  ; 
by  injeding  wines  and  other  liquids  into  the  cavity  of 
the  fac ;  by  irritation,  excited  with  tents  of  various 
kinds,  both  folid  and  hollow  ;  and  more  lately  by  the 
feton.  But,  however  keenly  one  and  all  of  thefe  me- 
thods had  for  a  time  been  fupported  by  thofe  who  firfl 
introduced  them,  they  were  at  lafl  entirely  laid  afide  ; 
fo  that,  for  thefe  lafl  five  years  and  more,  fcarcely  any 
has  been  attempted  through  the  greateil  part,  or  per- 
haps the  whole  of  Scotland,  but  that  by  incifion  :  and 
although,  as  I  have  obferved  above,  I  have  been  able 
to  trace  a  return  of  the  difeafe  in  four  inftances,  all  of 
them  from  caufes  which  ought  not  to  have  occurred, 
not  one,  fo  far  as  I  know,  has  died  of  the  operation. 

I  have  nov/  performed  this  operation  in  a  very  large 
number  of  cafes,  and  in  every  variety  of  age,  from 


Sea.  III.  On  the  Hydrocele.  83 

the  third  to  the  feventy-fifth  year :  not  one  of  the 
number  has  either  died  or  been  in  danger ;  nor  has 
the  difeafe  returned  in  any  of  them.  In  various  in- 
flances,  at  firft,  the  inflammation,  as  I  have  obferved 
above,  arrived  at  a  confiderable  height ;  but  not  in  a 
fmgle  inflance,  fmce  the  operation  has  been  done  in 
the  manner  I  have  mentioned. 

I  have  therefore  no  reafon  to  doubt  of  the  objec- 
tions which  have  been  made  to  this  operation,  being 
foon  done  away,  and  I  alfo  believe,  that  the  more  it  is 
put  in  practice,  the  Icfs  dread  will  be  entertained  of  it. 
For  my  own  part,  I  now  confider  it  as  a  matter  of 
nearly  the  fame  fimplicity  as  the  treatment  of  a  com- 
mon abfcefs  in  any  part  of  the  body.  The  cure  is 
conduced  upon  the  fame  principles.  It  is  accom- 
piiflied  in  the  fame  time ;  commonly  in  lefs  than  the 
cure  of  abfcelfes  of  equal  magnitude  ;  and,  from  the 
event,  I  am  warranted  to  fay,  that  it  is  not  attended 
with  more  hazard. 

Others,  from  not  being  fo  fortunate,  and  with 
whom  a  high  degree  of  inflammation  was  often  induc- 
ed, not  conceiving  that  this  inconvenience  could  be 
lelfencd,  either  by  any  alteration  to  be  made  in  the 
mode  of  performing  the  operation,  or  in  the  manage- 
ment of  the  dreflings,  were  naturally  induced  to  make 
trial  of  other  means  of  obtaining  a  radical  cure  of  the 
difeafe. 

The  late  Mr.  James  Rae  of  this  place,  who  was  per- 
haps one  of  the  bed  informed  pratlitioners,  as  I  be- 
lieve him  to  have  been  one  of  the  beft  operators  of 
the  age,  was  I  believe,  the  firfl:  who  revived  the  ufe  of 
the  feton  in  this  kingdom  for  the  cure  of  the  hydro- 
cele. He,  as  well  as  Mr.  Pott,  who  afterwards  wrote 
upon  it,  having  from  the  caufes  I  have  mentioned, 
conceived  a  dread  of  the  mode  of  operating  by  the 
fimple  incifion  ;  and  Mr.  Rae  having  previoufly  made 
many  unfuccefsful  trials  of  the  method  of  cure  by  in- 
jeding  wine  and  other  hquids  into  the  tunica  vagina- 
G  2 


H  On  the  Hydrccele.  Chap.  XXIV. 

lis  teftis,  they  both  keenly  adopted  the  pradice  with 
the  feton.  Being  ftrongly  recommended  by  two  fur- 
geons  of  fuch  reputation,  it  was  at  firft  adopted  by 
others  ;  but  the  inflammation  induced  by  it  was  found 
in  fome  inflances,  to  be  fo  great  and  alarming,  and 
the  dil'trefs  arifmg  from  matter  collecting  within  the 
tunica  vaginaHs,  and  from  the  openings  necefl'ary  for 
the  difcharge  of  it,  w^as  fo  confidcrable,  that  the  prac- 
tice never  got  into  general  ufe  ;  and  it  now  appears 
to  be  laid  afide  even  by  thofe  who  at  one  period  had 
formed  the  mofl:  favourable  opinion  of  it.  I  have  not 
heard  of  its  being  performed  in  a  fmgle  inflance  in 
this  place,  for  thefe  laft  twenty  years  :  it  feems  to  be 
falling^  into  difufe  in  Ensjland  ;  and  althou2;h  in  fome 
parts  of  the  Continent  it  was  at  firft  adopted,  on  the 
recommendation  of  Mr.  Pott,  I  do  not  now  learn  that 
it  is  ever  attempted. 

About  the  fame  period  that  Mr.  Pott  wrote  upon 
the  ufe  of  the  feton,  the  late  Mr.  Elfe  began  to  revive, 
with  fome  improvements,  the  method  of  curing  the 
hydrocele  with  cauflic  ;  and  if  any  fufficient  reafon 
had  occurred  for  laying  afide  the  operation  by  the  fim- 
ple  incifion,  I  would  have  been  of  opinion  that  the 
method  of  cure  recommended  by  Mr.  Elfe,  fliould 
have  been  preferred  to  every  other  with  which  we  are 
yet  acquainted.  It  gives  much  lefs  pain  than  the  fe- 
ton, and  it  cures  the  difeafe  with  equal  certainty. 

The  method  of  cure  by  excifion,  that  is,  by  cutting 
away  the  tunica  vaginalis,  cannot  be  compared  to  that 
by  the  fimple  incifion ;  for  it  does  not  accomplilh  a 
cure  more  quickly,  nor  with  more  certainty,  while  it 
obvioufly  renders  the  operation  much  more  tedious 
and  more  painful,  the  chief  reafons,  no  doubt,  for  this 
mode  of  operating  being  now  very  generally  exploded. 

The  laft  variety  of  operation  that  has  been  recom- 
mended for  the  cure  of  hydrocele,  is  alfo  the  revival 
of  an  old  one,  to  wit,  the  injecting  of  wine  and  other 
,  liquids  into  the  tunica  vaginalis  teftis. 


Sed.  III.  Oji  the  Hydrocek.  85 

The  merit  of  firft  propofing  the  cure  of  this  difeafe 
by  injeclions,  has  commonly  been  given  to  a  Mr. 
Munro,  a  furgeon  of  this  country  ;  but  we  now  have 
evidence  of  the  pradice  having  been  propofed  and 
adopted  upwards  of  fifty  years  fooner.  Tents,  armed 
with  irritating  ointments  having  long  been  employed, 
we  need  not  wonder  at  injec1:ion&  being  confidered  as 
a  better  method  of  conducting  the  fame  remedies  to 
the  parts  upon  w  hich  they  were  to  ad.  Whether  in- 
jections were  earlier  ufed  for  this  purpofe  or  not,  we 
do  not  certainly  know  ;  but  in  1677,  there  is  a  third 
edition  of  what  is  intituled  Les  Oeuvrcs  Chirurgicales, 
of  a  Monfieur  Lambert  at  Marfeilles,  in  which  a  par- 
ticular account  is  given  of  the  method  of  curing  hy- 
drocele by  injections.  The  liquid  Mr.  Lambert  pre- 
ferred, was  a  flrong  folation  of  corrofive  fublimate,  in 
lime  water ;  and  he  enumerates  many  cafes  in  which 
it  proved  fuccefsful.  But  whether  from  the  pain 
which  it  excited  being  fevere,  or  for  other  reafons 
with  which  we  arc  not  acquainted,  this  mode  of  ope- 
rating appears  to  have  been  for  a  long  time  laid  afide, 
till  it  was  afterwards  praCtifed  by  Mr.  Munro.  He  at 
firft  made  ufe  of  fpirit  of  wine ;  but  although  it  cur- 
ed the  difeafe,  the  pain  which  it  excited  was  fo  fevere, 
that  he  immediately  laid  it  afide,  and  employed  wine 
inftead  of  it. 

The  practice  being  favourably  received  by  fome  of 
the  firft  furgeons  of  this  place,  particularly  by  the  late 
Dr.  Monro,  Mr.  Douglas,  Mr.  Lauder,  and  the  late 
Mr.  Rae,  it  was  f^r  fome  time  frequently  praCtifed, 
efpecially  by  Mr.  Douglas  and  Mr.  Rae.  The  liquids 
they  employed  were  diluted  fpirit  of  wine,  lime  water, 
a  folution  of  alum,  and  red  wine,  both  by  itfelf,  and 
diluted. 

But  however  favourably  they  were  at  firft  induced 
to  judge  of  the  practice,  and  although  very  anxious 
for  its  fuccefs,  it  was  in  the  courfe  of  a  few  years,  laid 
afide  by  all  of  them,  and  evidently  upon  good  grounds. 
The  injedlion  either  excited  fevere  pain,  on  being  firft 


86  On  the  Hydrocele.         Chap.  XXIV. 

thrown  in,  and  was  fucceeded  by  violent  inflamma- 
tion, and  this,  in  fome,  by  diftrefsful  colledions  of 
matter  ;  or  the  cure  did  not  prove  permanent.  In  a 
few  cafes,  the  difeafe  returned  ahnoH  immediately, 
that  is,  in  the  courfe  of  two  or  three  weeks ;  but  this 
was  not  frequent.  For  the  mofl  part,  the  cure  ap- 
peared to  be  complete,  and  continued  to  be  fo,  till  at. 
fome  diftant  period,  to  the  great  difappointmcnt  both 
of  the  patient  and  furgeon,  a  recurrence  of  the  fwelU 
ing  was  obferved.  In  fome,  this  happened  in  five  or 
fix  months  ;  in  others,  not  till  three  or  four  years 
had  elapfed. 

About  the  fame  period,  fome  unfuccefsful  trials  be- 
ing made  with  injections  in  London,  both  by  the  late 
Mr.  Sharpe  and  others,  the  practice  was  altogether 
laid  afide  there,  as  it  had  been  here,  till  of  late  that 
fome  attempts  have  been  made  to  revive  it. 

But  although  for  a  period  of  more  than  forty  years, 
this  operation  was  fcarcely  heard  of  in  Britain,  it  was 
frequently  pradifed  in  France,  and  other  parts  of  the 
Continent,  where  many  trials  and  experiments  were 
made  for  curing  the  hydrocele  by  injetlions.  Trials 
were  made  with  fpirit  of  wine,  both  by  itfelf,  and  di- 
luted with  water  ;  with  a  folution  of  common  cauftic 
in  water,  in  the  proportion  of  two  grains  to  the  ounce  ; 
with  blue  vitriol  in  water,  in  the  fame  proportions  ; 
with  lime  water,  both  by  itfelf,  and  with  mercurius 
fubhmatus  corrofivus  dilfolved  in  it  in  various  propor- 
tions, from  a  quarter  of  a  grain  to  two  grains,  to  the 
ounce ;  with  ftrong  folutions  of  alum,  of  faccharum 
faturni,  infufions  of  red  rofe  leaves,  infufions  of  oak 
bark,  and  with  red  wine,  both  by  itfelf,  and  reduced 
with  water  to  various  degrees  of  ftrength,  according 
to  the  fancy  of  the  operator. 

Many  give  the  preference  to  an  infufion  of  red  rofe 
leaves  :  others  make  ufe  of  the  corrofive  fublimate  ; 
but  it  requires,  even  when  much  diluted,  to  be  ufed 
with  great  caution.  In  general,  the  preference  is  giv- 
en to  wine  :  when  claret  or  burgundy  are  employed. 


Bed:.  III.  On  the  Hydrccele.  87 

they  are  commonly  mixed  with  a  fixth  or  feventh  part 
of  water ;  and  when  port  is  ufed,  a  third  or  fourth 
part  of  water  is  added.  Where  no  pain  is  excited  by 
the  injection  thus  diluted,  the  liquid  fhould  be  dif- 
charged,  and  pure  wine  thrown  in  ;  for  where  no  pain 
takes  place,  a  cure  is  not  to  be  looked  for. 

The  operation  is  done  in  different  ways  ;  fome  pre- 
ferring a  lancet  for  making  the  opening  into  the  tu- 
mor, and  others  injedling  the  liquid  with  a  common 
fyringe  ;  but  in  my  opinion,  the  bed  method  of  per^- 
forming  it  is  the  following. 

The  furgeon  fliould  be  provided  with  a  flat  trocar, 
of  the  form  and  fize  reprefented  in  Plate  LVIII.  fig. 
3.  together  with  a  bag  of  refma  elaflica,  fitted  with  a 
pipe,  reprefented  in  the  fame  plate,  fig.  i.  The  pipe 
Ihould  be  fomewhat  longer  than  the  canula  of  the  tro- 
car, fo  as  to  pafs  about  an  eighth  part  of  an  inch  be^ 
yond  it.  If  longer  than  this,  it  might  injure  the  tef- 
tis  ;  and  when  fhorter,  the  liquid  does  not  pafs  fo  ea- 
fily.  The  quantity  of  liquid  to  be  injected  fhould  be 
gently  warmed,  and  put  into  the  bag  before  the  ope- 
ration is  begun.  The  patient  being  laid  in  a  horizontal 
poflure,  either  upon  his  bed  or  on  a  table,  and  fecur- 
ed  in  the  ufual  way  by  afiiflants,  the  water  fhould  be 
drawn  entirely  olf  from  the  tumor,  by  pafling  the  tro- 
car into  the  anterior  and  mofl  depending  part  of  it. 
The  operator,  fecuring  the  canula  of  the  trocar  with 
his  left  hand,  is  now  with  his  right,  to  pafs  the  tube 
of  the  inje£lion  bag  entirely  through  it,  and  with  gen- 
tle prefl'ure,  to  force  as  much  of  the  liquid  which  it 
contains  into  the  cavity  of  the  tunica  vaginalis,  as  may 
be  neceffary  for  eafily  reaching  every  part  of  it,  as  well 
as  the  whole  furface  of  the  teftis.  The  bag  fhould 
now  be  removed,  taking  care  to  leave  the  tube  within 
the  canula  of  the  trocar,  fo  that  by  turning  the  flop 
cock,  the  liquid  may  be  retained  in  the  cavity  of  the 
tumor.  The  furgeon  fliould  fHU  keep  the  canula  of 
the  trocar  fixed,  otherwife  it  might  recede,  by  which 
the  liquid  would  infmuate  into  the  cellular  fubftance 


88  On  the  Hydrocele.  Chap.  XXIV. 

cf  the  fcrotum,  and  in  this  manner  do  harm.  He 
ihould  aifo,  with  very  gentle  prefl'ure,  make  the  liquid 
pafs  to  every  part  of  the  cavity  during  the  time  it  is 
retained  in  it  ;  and  at  the  end  of  four  minutes,  it 
fliould  be  entirely  difcharged  through  the  canula  of 
the  trocar,  after  withdrawhig  the  tube  of  the  elaflic 
bag. 

Some  have  faid  that  the  injedion  fhould  be  retain- 
ed about  three  minutes  :  others  think  that  it  cannot 
be  depended  on  in  lefs  than  fix  or  feven.  But  thofe 
who  have  operated  mofl  frequently  in  this  manner, 
are  of  opinion,  that  the  fpace  of  four  minutes  is  better 
than  either.  It  fometimes  happens  that  intenfe  pain 
is  given  almofl  inilantaneoufly  on  the  injedion  being 
introduced.  In  this  cafe,  it  fliould  be  difcharged  as 
foon  as  it  has  been  made  to  pafs  to  the  different  parts 
of  the  tunica  vaoinalis. 

o 

'  Some  again  are  of  opinion,  that  after  the  quantity 
of  liquid  firft  injected  is  difcharged,  a  fimilar  quantity 
fhould  be  immediately  thrown  in,  and  retained  for  the ' 
fame  length  of  time,  and  that  the  operation  will  be 
very  apt  to  fail  if  this  is  omitted.  This  however,  is 
feldom  done,  although  I  believe  it  would  be  a  real 
improvement  on  the  operation. 

The  quantity  of  liquid  to  be  inje6ied,  fl:ould  always 
depend  on  the  fize  of  the  tumor.  Some  have  thought 
that  it  fliould  be  equal  to  the  quantity  drawn  off  by 
the  operation  ;  but  this  does  not  appear  to  be  neceffa- 
ry,  while  the  injeding  of  fuch  a  quantity  is  apt  to  do 
•harm.  After  having  collapfed  completely,  the  parts 
do  not  again  yield  eafily  to  fudden  diftention  ;  fo  that 
violent  pain  has  been  induced  by  it.  Where  the  tu- 
mor is  fmall,  that  is,  where  only  five  or  fix  ounces  of 
ferum  are  collefted,  the  quantity  of  injection  need  not 
exceed  three  or  four  ounces  ;  while  it  fhould  not  be 
lefs  than  feven  or  eight  ounces,  where  a  pound  of  fe- 
rum has  been  drawn  off;  and  in  this  proportion,  ac- 
cording to  the  fize  of  the  tumor. 


i 


Se£t.  III.  On  the  Hydrocele,  89 

Lefs  than  any  of  thefe  quantities  might  anfwer  ; 
but  it  would  require  more  handling  to  bring  it  into 
contad  with  all  the  parts  which  it  ought  to  touch  ; 
and  as  a  larger  quantity  is  eafily  introduced,  it  fhould 
always  be  advifed. 

On  the  injection  being  difcharged,  and  not  a  drop 
fliould  be  left,  the  fcrotum  fhould  be  covered  with  a 
pledget  of  common  cerate,  a  comprefs  being  applied 
over  it,  and  retained  with  a  fufpenfory  bag.  The  pa- 
tient fhould  be  defired  to  remain  in  bed  for  feveral 
days,  and  to  give  aid  to  the  fufpenfory  bandage,  by 
inferting  a  fmall  pillow  beneath  it. 

It  often  happens,  that  the  pain  is  inconfiderable  from 
the  firfl  ;  fcarcely  any  inflammation  or  tumor  being 
perceived  on  the  teilis  ;  and  the  patient,  confidering 
himfelf  as  well,  walks  abroad,  in  ten,  twelve,  fourteen, 
or  fifteen  days.  But,  with  others,  a  very  fevere  degree 
of  pain  takes  place  on  the  firfl  introduftion  of  the  in- 
jection, not  merely  in  the  teflis,  but  in  the  back,  and 
over  the  whole  loins.  In  mofl  inflances,  this  foon  be- 
comes moderate,  and  the  treatment  goes  eafily  on  ; 
but,  in  others,  it  is  fucceeded  by  great  inflammation 
in  the  teilis  and  fcrotum  ;  and,  in  a  few,  this  termi- 
nates in  colleclions  of  matter  within  the  cavity  of  the 
tunica  vaginalis. 

Thefe  violent  fymptoms  the  praftitioner  endeavours 
to  obviate  by  bloodletting,  a  low  diet,  the  ufe  of  lax- 
atives, and  all  the  remedies  ufually  employed  in  her- 
nia humoralis  ;  fuch  as  all  the  faturninc  applications  ; 
and  warm  emollient  fomentations  and  poultices,  when, 
fuppuration  is  likely  to  take  place. 

When  matter  forms  in  the  tunica  vaginahs,  the 
treatment  confills  in  laying  the  cclleclion  open  from 
one  end  to  the  other,  and  ccnduding  the  cure,  as  has 
already  been  advifed  in  the  operation  by  the  fmiple  in- 
cifion.  The  formation  of  matter,  I  believe,  is  not  fre- 
quent ;  but  I  know  that  it  occafionally  happens  ;  and 
io  much  are  the  pra£litioners  on  the  Continent  afraid 
of  it  J  of  the  height  to  which  the  inflammation  might 


90  On  the  Hydrocele.  Chap.  XXIV. 

othervvlfe  advance  ;  and  of  the  dreadful  diftrefs  that 
in  fuch  circumflances  enfuc,  from  fuppuration  taking 
place,  that  they  feldom  perform  the  operation  without 
premifmg  purging  and  bloodletting,  and  often  repeat 
the  bloodletting  once  and  again  during  the  cure,  pre- 
cautions never  judged  neceifary  in  the  method  of  cur- 
ing the  hydrocele  by  the  fimple  incifion. 

The  proportion  of  thofe  that  are  radically  cured  by 
this  method  of  operating,  it  is  difficult  to  afcertain ; 
for,  although  in  fome  the  difeafe  returns  in  the  courfe 
of  two  or  three  weeks  ;  in  others,  it  is  not  perceived 
for  feveral  months  j  and,  in  fome,  as  I  have  obferved 
above,  not  till  two  or  three  years  have  elapfed.  Hence, 
in  hofpltal  practice,  where  patients  are  feldom  heard 
of  after  being  difmilfed,  the  point  in  queftion  cannot 
be  determined  ;  and  it  is  chiefly  in  foreign  hofpitals 
that  hitherto  this  operation  has  been  performed.  From 
the  befl  information  that  I  have  been  able  to  procure, 
it  appears,  that  although,  in  many,  a  complete  cure  is 
obtained,  yet  that  the  difeafe  returns  early,  that  is,  in 
the  fpace  of  a  few  weeks,  in  a  ninth  or  tenth  part  of 
all  on  whom  the  operation  is  performed ;  and  in  five 
of  eight  or  nine,  at  fome  uncertain  period  in  future. 

Under  this  conviclion,  I  have  judged  it  proper  to 
ftate  all  that  has  come  to  my  knowledge  of  what  re- 
lates to  this  operation  ;  and  I  am  the  more  induced  to 
it,  from  finding  that  others,  either  from  an  unneceffa- 
ry  dread  of  the  operation  by  the  fimple  incifion,  and 
which  I  confider  as  the  befl  and  moft  rational  that  is 
yet  known,  or  from  a  mifreprefentation  in  the  accounts 
they  may  have  received  of  the  method  of  cure  by  in- 
je£tion,  are  again  endeavouring  to  introduce  it  in 
Britain. 

From  the  hiftory  that  I  have  given  of  the  method 
of  curing  the  hydrocele  by  injeftions,  the  conclufion 
that  I  have  formed  of  it  would  readily  be  drawn  by 
any  one ;  but,  in  addition  to  this,  many  powerful  ar-» 
guments  may  be  adduced  againfl  it. 


Sea.  III.  On  the  Hydrocele.  9! 

I  ft,  We  do  not,  from  experience,  find,  that  other 
tumors,  produced  by  fluids  contained  in  cyfts,  are 
readily  cured  by  inje£lions.  Few,  I  believe,  would 
now  think  of  attempting  the  cure  of  abfcefles  or  en- 
cyfled  tumors  by  injections.  In  tumors  induced  by 
fluids  collected  in  the  burfas  mucofas,  where,  from  the 
contiguity  of  joints,  extenfive  incifions  might  have 
done  harm,  I  have  in  various  infl:ances,  made  trial  of 
injedions  ;  but  feldom  with  any  advantage.  In  fome, 
they  excite  pain  and  inflammation ;  and  where  this 
does  not  happen,  although  they  may  leflen  the  dif- 
charge,  this  proves  only  temporary ;  fo  that  a  cure  is 
afterwards  to  be  obtained  by  the  introduction  of  a  cord, 
or  the  enlargement  of  the  opening  to  as  great  an  ex- 
tent as  with  fafety  can  be  ventured  upon. 

Mr.  Earle,  indeed,  has  faid,  and  he  gives  it  as  a  rea- 
fon  for  the  pradice  he  has  adopted  in  hydrocele,  that 
he  has  frequently  fucceeded  in  procuring  adhefion  and 
confolidation  of  parts  in  finufes,  and  other  large  cavi- 
ties, by  injedlions  of  various  kinds  :  but,  as  this  has 
neither  happened  in  the  courfe  of  my  own  experience, 
nor  with  any  other  practitioner  with  whom  I  am  ac- 
quainted, I  mufl  leave  the  practice  in  the  hands  of  thofe 
with  whom  it  has  anfwcred  better. 

At  one  period,  a  practitioner  in  this  country  got  in- 
to notice,  by  announcing  frequent  cures  of  the  filtula 
in  ano  as  well  as  other  finufes,  by  injections.  Some 
timid  patients,  both  here  and  from  England,  put  them- 
felves  under  his  care.  His  reputation,  however,  was 
not  of  long  duration  ;  for  I  do  not  find  that  he  prov- 
ed fuccefsful  in  one  of  twenty  cafes,  although  the  pa- 
tients commonly  remained  long  under  his  care.  The 
injections  were  thrown  in  frequeetly,  and  with  much 
attention  ;  and  liquids  of  various  kinds  were  employ- 
ed ;  fome  that  feemed  to  aCt  folely  by  their  afl:ringen- 
cy,  and  others  by  exciting  inflammation. 

2d,  When  the  tunica  vaginalis  has  been  much  dif- 
tended,  as  it  will  not  collapfe  equally  round  the  tefti- 
ele  ou  the  fluid  being  drawn  off",  cavities  will  thus  be 


92  On  the  Hydrocele.  Chap.  XXIV. 

formed,  by  which  feparate  colledtions  will  be  apt  to 
take  place,  either  of  a  ferous  fluid,  or  of  purulent  mat- 
•ter,  if  inflammation  has  been  excited.  This  was  my 
opinion  of  the  probable  effect  of  injeclions,  long  be- 
fore the  lafl  edition  of  this  volume  was  publiflied  ; 
and  fmce  that  period,  different  cafes  have  occurred, 
which  render  it  certain  that  the  fufpicion  was  well 
founded. 

3d,  When  inflammation,  excited  by  an  injcdion, 
goes  too  far,  and  with  whatever  care  the  operation  is 
done,  it  fometimes  happens,  the  diftrefs  produced  by 
it  is  fevere.  Befides  the  pain  arifmg  from  the  inflam- 
matory fl:age  of  the  difeafe,  if  fuppuration  takes  place, 
the  patient  mud  fubmit  to  that  painful  dillention  which 
the  fudden  formation  of  matter  in  this  confined  ftate 
always  excites  ;  to  the  febrile  fymptoms  with  which  it 
is  attended  ;  and  to  an  incifion  equally  extenfive  for 
difcharging  the  matter,  as  if  the  mode  of  cure  by  in- 
cifion had  been  adopted  at  firfl: . 

4th,  The  fl:ate  of  the  teftis  cannot,  in  this  mode  of 
operating,  be  examined  with  the  fame  accuracy,  as 
when  the  operation  is  done  by  incifion.  Hence  it 
may  be  in  fuch  a  ftate  of  difeafe  as  to  be  injured  by 
the  injedion,  without  our  being  previoufly  able  to  dis- 
cover it. 

Some  indeed  have  faid,  that,  on  the  water  being 
drawn  off,  we  may  always  know  with  certainty  wheth- 
er the  tefticle  is  found  or  not.  This  when  it  is  much 
enlarged,  is  certainly  the  cafe ;  but  where  the  tunica 
vaginalis  is  thickened,  as  it  generally  is  when  it  has 
been  long  much  diftended,  the  teftis,  if  not  confidera- 
bly  enlarged,  as  well  as  the  epididymis,  maybe  mate- 
rially difeafed,  Vvithout  our  being  able  to  difcover  it. 
Of  this  I  have  feen  various  inftances ;  in  fome  of 
which,  as  I  have  obferved  above,  practitioners  of  much 
experience  were  deceived. 

5th,  The  views  of  modern  furgeons  in  the  cure  of 
the  hydrocele,  are,  as  I  have  already  had  occafion  to 
remark,  to  excite  fuch  a  degree  of  inflammation  over 


Se£l.  IIL  On  the  Hydrocele.  93 

the  furface  of  the  telllcle,  as  well  as  of  the  tuiiica  va- 
ginalis, as  may  produce  a  firm  adhefion  between  them. 

Now,  inftances  often  occur,  in  which  the  tunica  va- 
ginalis is  fo  thick,  callous,  and  infeniible,  that  a  much 
more  irritating  injeclion  would  be  required  to  make  it 
inflame  than  the  tefticle  itfelf  can  bear. 

Nay,  cafes  are  fometimes  met  with,  in  which  differ- 
ent portions  of  the  tunica  vaginalis  are  as  firm  and 
hard  as  cartilage ;  a  (late  highly  improper  for  any  at- 
tempt to  cure  the  difeafe  by  injedions,  or  in  any  other 
way  than  by  removing  the  hardened  parts ;  and  yet 
this  fometimes  happens,  as  I  have  more  than  once  feen, 
where  previoufly  it  could  not  be  difcovered,  and  in 
which  the  tunica  vaginalis  teflis  appeared  to  be  in  its 
ufual  (late,  till  the  contrary  was  found  to  be  the  cafe, 
on  laying  the  parts  open  by  fimple  incifion, 

6th,  The  chief,  and  perhaps  only  advantage  which 
the  mode  of  operating  by  injeftion  feems  to  poffefs, 
over  that  by  incifion,  is,  that  it  is  lefs  painful  in  the 
execution  ;  but  although  this  may  be  a  reafon  for  ad- 
vifing  it  with  timid  patients,  v/ho  will  not  fubmit  to 
the  other,  it  is  not  fuflicient  to  warrant  praditioners 
in  giving  it  the  preference.  The  prevention  of  pain 
is  at  all  times  a  mod  dcfirable  objedl ;  but  it  is  far 
from  being  the  only  one  in  chirurgical  operations. 
Our  chief  view,  is  the  fafety  of  our  patient  in  the  fir  ft 
inllance,  together  with  his  complete  fecurity  againil  a 
return  of  the  difeafe.  In  fo  far  as  OPxe  mode  of  oper- 
ating is  lefs  painful  than  another,  and  attended  with 
equal  certainty  in  fecuiing  againfl  a  relapfc,  it  ought 
certainly  to  be  preferred  ;  but  this  is,  as  I  have  already 
had  occafion  to  remark,  far  from  being  the  cafe  with 
the  mode  of  curing  the  hydrocele  by  injedions  ;  fo 
that  patients  .treated  in  this  manner,  are,  for  a  confid- 
erable  time,  liabl^to  all  the  diftrefs  and  anxiety,  which 
uncertainty  in  points  of  importance  in  every  inftance 
gives,  while  the  chief  difference  between  it  and  the 
method  of  operating  by  incifion,  which  I  have  fliewn 
to  be  attended  with  complete  fafety  as  well  as  fecurity. 


94  On  the  Hydrocele,  Chap.  XXIV. 

confifts  In  the  degree  of  pain  which  it  excites  being 
lefs.  This  of  itfelf  would  have  httle  influence  even 
with  the  mod  timid,  were  they  to  know,  that,  in  the 
mode  of  operating  by  incifion,  the  cutting  part  of  it 
is  done  in  lefs  than  a  minute ;  when  the  dreflings  are 
properly  conducted,  that  the  tefticle  does  not  inflame 
more  than  is  necefl^ary  for  a  cure  ;  and  that  the  fubfe- 
quent  pain  is  for  the  mod  part  inconfiderable  ;  not  to 
be  compared  with  what  is  experienced  from  matter 
colledting  within  the  cavity  of  the  tunica  vaginalis,  as 
fometimes  happens  in  the  mode  of  operating  by  injec- 
tion, as  well  as  in  that  by  the  feton. 

7th,  As  an  argument  in  favour  of  this  operation.  It 
is  faid,  that  when  it  fails,  we  ftill  have  it  in  our  pow- 
er to  perform  it  over  again,  or  to  advife  the  radical 
cure  by  incifion.  This,  however,  leads  to  much  vex- 
ation, diftrefs,  and  difoppointment  in  the  firfl:  inflance, 
while  I  think  it  probable,  that  one  eft'ecl  of  injeftions* 
when  they  do  not  fucceed,  mud  be  to  render  any  oth- 
er operation  that  may  be  afterwards  performed  more 
uncertain  than  it  otherwife  would  be,  or  to  require  a 
higher  degree  of  inflammation  to  be  induced.  Some 
have  imagined,  that  injections  in  the  cure  of  hydrocele 
prove  ufeful,  only  in  fo  far  as  they  excite  inflamma- 
tion, and  confequent  adhefion  of  the  tunica  vaginalis 
to  the  furface  of  the  tefl:is  ;  whilft  others  are  of  opin- 
ion, that  they  aft  folely  by  their  aftringency.  By 
ftrengthening  or  corrugating  the  fecreting  and  abfor- 
bent  veflTels  of  the  parts,  they  may  be  fuppofed  to  a61: 
both  by  preventing  a  too  plentiful  fecretion  of  the  flu- 
id naturally  contained  in  the  tunica  vaginalis,  and  by 
promoting  a  more  equal  abforption  ;  and  we  accord- 
ingly find,  that  fuch  fluids  only  are  now  ufed  for  thefe 
injections,  as  are  in  a  confiderable  degree  aftringent, 
fuch  as  infufions  of  red  rofe  leaves,Tolutions  of  alum, 
and  red  wine. 

My  own  opinion  is,  that  a  permanent  cure  is  never 
to  be  depended  on,  where  inflammation  is  not  induc- 
ed fufFicicnt  to  produce  a  firm  adhefion  between  the 


I 


Se£l.  III.  0?i  the  Hydrocele.  95 

tunica  vaginalis  and  teftis  ;  but  there  is  rcafon  to  think, 
that  this  feldom  takes  place  from  injections ;  and  I 
conclude  that  it  is  fo,  not  only  from  the  trifling  degree 
of  pain  which,  in  moft  inftances,  the  injeftions  now 
ufed  commonly  give,  and  from  the  fwelling  of  the 
parts,  which  ufually  takes  place,  being  inconfiderable, 
but  from  the  difcafe  often  returning,  after  it  had  been, 
fuppofed  to  be  cured,  and  which  could  not  happen,  if 
thefe  parts  had  been  made  to  unite  by  inflammation. 

Now,  if  this  is  the  fa6l,  and  I  firmly  believe  it  to  be 
fo,  that  injeclions,  in  a  great  proportion  of  cafes,  act 
chiefly  by  their  aftringency,  and  not  by  deftroying  the 
cavity  of  the  tunica  vaginalis,  thcv  may  readily  be  fup- 
pofed to  render,  not  only  the  tunica  vaginalis,  but  ev- 
en the  furface  of  the  teftis  more  callous  than  it  was  be- 
fore, by  which  a  greater  degree  of  inflammation  will 
be  required,  than  might  otheiAvife  be  fufficient,  when 
any  other  operation  becomes  necefl'ary  for  a  perma- 
nent cure. 

In  anfwer,  however,  to  all  thefe  objections,  it  may 
be  faid,  that  the  practice  has  already  gained  ground  in 
feveral  parts  of  the  Continent,  and  that  Mr.  Earle,  a 
furgeon  of  our  own  country,  has  brought  forth  two 
publications  on  the  fubjed,  in  both  of  which  it  is  re- 
commended in  the  warmeft  manner,  and  a  number  of 
cafes  recited,  in  which  it  appears  to  have  proved  fuc- 
cefsful. 

To  this  I  fliall  only  obferve,  what  I  have  already 
had  occafion  to  do,  refpedling  the  pradice  of  foreign- 
ers in  the  hydrocele  ;  that  having  been  later  than  the 
Britifli  furgeons,  in  acquiring  a  knowledge  of  the  true 
nature  of  the  difcafe,  they  have  hitherto  remained  be- 
hind them  in  every  thing  that  relates  to  it.  Their 
pradice  has  therefore  been  timid,  changeable,  and  in- 
decifive.  This,  however,  I  only  mean  as  a  general  cb- 
fervation  ;.  for  fome  foreigners  there  are,  whofe  know^ 
edge  in  this,  as  in  all  other  difeafes,  would  do  them 
much  honour :  but  all  who  have  read  what  in  goner- 


96  On  the  Hydrocele.  Chap.  XXIV. 

al  has  been  written  upon  this  fubjcct  by  foreign  fur- 
geons,  or  who  have  had  opportunities  of  feeing  their 
pradice,  mufl  admit,  that  in  the  treatment  of  hydro- 
cele they  ought  not  to  be  followed. 

And  again,  with  refpecl  to  the  obfervation  of  Mr. 
Earle,  I  need  only  obferve,  that  this  writer  obvioufiy 
labours  under  a  deep  rooted  prejudice  againft  every 
mode  of  operating,  except  that  by  the  feton,  of  which 
he  once  feems  to  have  entertained  a  very  high  opinion, 
and  the  mode  of  cure  by  injedlion,  which  he  has  now 
very  keenly  adopted.  In  one  part,  indeed,  of  his  trea- 
tife,  he  makes  the  following  candid  declaration :  "  I 
*'  mufl  confefs,  that  1  took  an  early  and  deep  rooted 
*'  diflike  to  the  cure  of  hydrocele  by  incifion."*  La- 
bouring under  this  kind  of  terror  at  other  operations, 
and  diiappointed,  as  it  would  feem,  in  his  cxpeftation 
of  the  operation  by  the  feton,  he  was  thus  ready  to 
adopt  the  practice  of  curing  the  difeafe  v»'ith  injedions, 
in  the  eafy  manner  rcprefented  by  the  French,  and 
which  he  has  accordingly  Vv'ith  great  zeal  done. 

If  longer  experience,  and  farther  improvement,  fhall 
evince  the  mode  of  curing  the  hydrocele  by  injections 
to  be  equally  fafe  and  certain  with  that  by  the  fimple 
inciiion,  and  fhall  obviate  the  objeclions  that  I  have 
ftated  againft  it,  none  will  be  more  ready  to  adopt  it 
than  I  fhall  be.  In  the  mean  while,  and  in  the  pre- 
fent  flate  of  our  knowledge,  few  practitioners  will  ad- 
vife  it,  if  it  be  not  with  thofe  patients  whofe  timidity 
precludes  the  more  certain  and  equally  fafe  method 
of  cure,  the  operation  by  incifion. 

*  Vide  A  Treatlfe  on  the  Hydrocele,  Sec.  by  James  EarIe,Efq.  p.  30. 


Se£l.  IV.  On  the  Hydrocele,  97 

SECTION     IV. 

Of  the  Hydrocele  of  a  Hernial  Sac. 

WHEN  the  parts  have  been  long  protruded  in 
hernia,  a  lerous  fluid  colleds  in  the  bottom 
of  the  fac.  In  the  fcrotal  hernia,  if  this  extravafated 
ferum  is  not  foon  removed  by  abforption,  the  tumor, 
we  may  eafily  imagine,  may  augment  to  fuch  a  fize  as 
to  aftbrd  many  of  the  ufual  marks  of  a  hydrocele. 
Accordingly,  befides  diiferent  inftances  that  I  have 
now  met  of  it  in  my  own  pradice,  a  number  of  ca- 
fes, I  find,  are  enumerated  by  authors,  which  fuffi- 
ciently  warrant  the  infertion  of  this  as  a  real,  and  per- 
haps not  an  unfrequent,  variety  of  the  difeafe. 

It  was  well  known  to  the  ancients,  that  a  confider- 
able  quantity  of  a  fluid  is  frequently  contained  in  the 
fac  of  a  hernia,  along  with  the  parts  protruded  from 
the  abdomen ;  but  Saviard  feems  to  have  been  the 
firfl:  who  fpeaks  of  it  with  precifion.  Le  Dran  re- 
lates difl:erent  cafes  of  it :  Heifl:er  fpeaks  of  it  under 
the  title  of  hydro-entrocele  ;  and  the  late  Dr.  Monro 
defcribes  it  with  his  ufual  accuracy,  and  mentions  a 
cafe  of  it  where  fix  pounds  of  water  were  evacuated 
from  the  tumor,  by  an  opening  made  with  a  trocar.* 
A  cafe  of  it  is  alfo  related  by  Douglas,!  and  two  cafes 
of  a  fimilar  nature  are  mentioned  by  Mr.  Pott.| 

The  ferum  is  here  confined  in  a  cyft,  formed  by  a 
procefs  of  the  peritonaeum  ;  and,  as  it  occupies  near- 
ly the  fame  fituation  in  the  fcrotum  with  the  hydro- 
cele of  the  tunica  vaginalis,  fo  we  cannot  always,  by 
the  feeling  alone,  mark  the  difl'erence  between  them. 
For,  although  the  tcfl.icle,  in  this  variety  of  hydrocele, 

•  Monro's  Works,  p.  579.  f  P.  18a. 

\  Treatife  on  tlic  Hydrocele,  p.  21. 

Vol.  hi.  H 


9^  0?i  the  Hydrocele.  Chap.  XXIV* 

is  commonly  diftinguiihed  more  evidently  at  the  low- 
er and  pofterior  part  of  the  fwelling,  than  in  the  hy- 
drocele of  the  vaginal  coat,  yet,  the  dill'erence  in  this 
particular  between  the  two  difeafes,  is  not  always  fo 
evident  as  to  afford  fufficient  means  of  diilinflion. 

When  a  portion  of  gut,  and  other  paits  forming  a 
hernia  are  down,  the  fulnefs  they  produce  along  the 
fpermatic  cord,  ferves,  in  fome  meafure,  to  diitinguilh 
the  difeafe  from  a  funple  hydrocele.  And  when, 
along  with  this  and  other  fymptoms  of  hernia,  we  evi- 
dently diicover,  in  the  tumor  of  the  fcrotum,  a  fluc- 
tuation of  a  fluid,  if  this  fluid  can,  by  preflure,  be  made 
to  difappear,  either  entirely  or  in  part,  the  nature  of 
the  cafe  becomes  thereby  obvious. 

This  variety  of  hydrocele  may  take  place  as  readily 
in  the  hernia  congenita,  as  in  any  other  rupture  ;  and, 
in  that  event,  the  water  mull  be  contained  in  the  fame 
fac  with  the  telHcle  and  protruded  inteflines. 

As  all  the  fluid  indeed  naturally  fecreted  for  keep- 
ing the  furface  of  the  abdominal  vifcera  moifh,  muft, 
in  a  congenital  hernia,  fall  into  the  fac,  we  would  be 
induced  to  fuppofe,  that  almofl;  every  hernia  of  this 
kind  Ihould  be  complicated  with  a  hydrocele  of  the 
fac.  The  two  cafes  of  this,  related  by  Mr.  Pott,  ap- 
pear to  have  been  conneded  with  hernia  congenita ; 
and  I  have  met  with  it  in  different  inftances.  But 
whether  this  commonly  happens  or  not,  further  ob- 
fervation  muft  difcover. 

With  whatever  hernia  this  kind  of  hydrocele  is  con- 
ne£led,  if  the  water  can,  by  preffure,  be  made  to  pal's 
into  the  abdomen,  this  will  always  prove  certainly 
charaderiftic  of  the  difeafe ;  for,  in  no  other  fpecies 
of  encyfted  hydrocele,  can  the  water  be  made  to  dif- 
appear by  prellure.  It  may  happen,  hov/ever,  in  this 
kind  of  hydrocele,  that  this  diftinguiflnng  fymptom  of 
the  difeafe  does  not  exift  ;  for  if,  by  tlie  preffure  of  a 
trufs,  or  any  other  caufe,  an  adhefion  is  produced  in 
the  groin,  between  the  fides  of  the  hernial  fac,  if  the 
under  part  of  the  fac  continues  open,  with  water  col- 


Sc£t.  IV.  On  the  Hydrocele,  99 

leiSled  in  it,  the  tumor  produced  by  it  will  afford  all 
the  ufual  appearances  of  hydrocele,  while  no  part  of 
its  contents  can  be  made  to  pafs  into  the  abdomen  by 
preifure.  A  cafe  of  this  kind  we  find  related  by  Le 
Dran,  where  the  neck  of  the  hernial  fac  was  fhut 
completely,  and  a  hydrocele  formed  in  the  under  part 
of  it. 

In  this  fituation,  the  chief  means  of  diftindion  are 
to  be  obtained  from  an  acquaintance  with  the  previ- 
ous hiftory  of  the  cafe.  When,  in  an  ambiguous  cafe, 
it  is  found,  that,  before  the  water  began  to  colled  in 
the  fcrotum,  the  patient  had  been  liable  to  a  hernia  of 
the  fame  fide,  this  circumflance  alone  will  tend  much 
to  determine  the  nature  of  the  difeafe.  But  even  al- 
though a  miftake  fliould  occur,  and  although  a  hy- 
drocele of  a  hernial  fac  (liould,  in  fuch  circumflances, 
be  miftaken  for  a  fnnple  hydrocele  of  the  tunica  vagi- 
nalis, nothing  bad  could  enfue  from  it ;  for  the  treat- 
ment adapted  to  one  variety  of  the  difeafe,  would  ap- 
ply with  nearly  equal  propriety  to  the  other  ;  for  here 
we  conclude,  that  the  parts  which  at  firft  formed  the 
hernia  are  reduced,  and  that  the  fides  of  the  fac,  in 
the  upper  part  of  it,  adhere  firmly  together. 

But,  when  the  protruded  parts  (till  remain  down, 
unlefs  the  operation  for  the  bubonocele  is  at  the  fame 
time  to  be  performed,  no  other  fliOuld  be  attempted, 
but  that  of  difcharging  the  water  with  a  fmall  trocar, 
when  the  fize  of  the  tumor  renders  it  proper.  For, 
unlefs  the  operation  for  the  hernia  fliould  be  done  at 
the  fame  time,  much  harm  might  enfue  from  expof- 
ing  the  bowels  fo  much  to  the  air,  as  would  neceffa- 
rily  be  the  cafe,  by  laying  the  tumor  open  for  a  radi- 
cal cure  of  the  hydrocele. 

Whenever  it  is  refolved,  in  this  variety  of  hydro- 
cele, to  operate  for  a  radical  cure,  the  fimple  incifion 
ought  unqueflionably  to  be  advifed  ;  as,  from  the  rifk 
of  injuring  the  bowels  protruded  from  the  abdomen, 
neither  the  feton,  cauftic,  nor  injections,  are  here  ad- 
H  2 


100  On  the  Hydrocele.  Chap.  XXIV. 

miffible.  Indeed,  this  of  itfelf  affords  a  powerful  ar- 
gument in  favour  of  the  method  of  operating  in  every 
inftance  by  the  fmiple  incifion,  which  brings  all  the 
parts  concerned  in  the  difeafe  into  view.  The  very 
poiTibihty  of  a  patient  being  killed,  by  a  feton  pafTmg 
through  a  portion  of  intefline  contained  in  a  hydro- 
cele, is  a  weighty  objedlion  againft  the  feton  being 
ever  employed  ;  and  every  praditioner  mufl:  acknow- 
ledge, that  when  the  fpermatic  procefs  along  the  groin 
is  much  diftended,  and  the  vaginal  coat  of  the  teftis 
much  thickened,  that  fuch  uncertainty  often  occurs, 
as  to  render  it  impoiTible  for  the  mod  {ls.ilful  furgeons 
to  determine  with  precifion,  what  the  contents  of  fuch 
fwellings  really  are.  In  the  inftances  to  which  I  al- 
lude, of  a  hydrocele  connefted  with  a  congenital  her- 
nia, and  which  I  met  with  fome  years  ago,  there  had 
not  been  previoufly  any  caufe  to  fufpect  the  real  na- 
ture of  the  cafe.  They  were,  by  fkilful  praftitioners, 
judged  to  be  collections  of  water  in  the  tunica  vagina- 
lis, without  any  complication  whatever  ;  and,  on  the 
tumor  being  laid  open,  together  with  water  in  contact 
with  teflicle,  a  piece  of  intefline  was  found  protruded 
into  the  upper  part  of  the  fcrotum.  In  one  of  the 
cafes  too,  a  fmall  portion  of  omentum  accompanied 
the  gut. 

In  this  laft,  it  had  been  propofed,  at  a  confultation 
of  furgeons,  to  employ  the  feton.  For  fome  reafon 
or  other,  this  was  fortunately  rejefted  ;  for,  on  laying 
the  tumor  open  by  incifion,  it  evidently  appeared,  that 
if  a  cord  had  been  introduced,  it  mufl  in  all  probabi- 
lity have  paifed  through  the  protruded  gut. 


Se£l.  V.  On  the  Hydrocele.  lol 

SECTION    V. 

Of  the  Anafarcous  Hydrocele  of  the  Spermatic  Cord. 

IN  the  anatomical  defcription  given  in  the  firft  fec- 
tion  of  this  chapter,  it  was  obferved,  that  foon  af- 
ter the  defcent  of  the  teftis,  the  paflage  along  the  fper- 
matic  procefs  of  the  peritonaeum ,  is  completely  oblit- 
erated, by  the  fides  of  the  paflage  adhering  together. 

By  external  prefl"ure,  and  in  fome  inftances,  per- 
haps from  other  caufes,  this  adhefion  of  the  fides  of 
the  peritoneal  procefs,  is  in  general  very  firm  in  that 
part  of  it  which  pafles  along  the  groin ;  but  the  fupe- 
rior  and  more  internal  part  of  the  procefs,  is  not  only 
more  loofe  in  itfelf,  but  is  connected  with,  and  envel- 
oped in  a  very  loofe  cellular  fubftance. 

From  this  cellular  ftrudure  of  thefe  parts  we  might 
a  priori,  fuppofe  them  to  be  liable  to  the  fame  kind  of 
anafarcous  or  cedematous  fwellings,  with  which  other 
parts  of  the  body,  of  a  fimilar  flrutlure,  are  frequent- 
ly attacked  ;  and  accordingly  we  find  that  this  is  the 
cafe.  This  anafarcous  fwelling  fometimcs  accompa- 
nies afcites  ;  and  it  now  and  then  appears  locally,, 
without  being  combined  with  either  of  thefe. 

The  caufes  of  this  variety  of  hydrocele  in  general, 
are,  obftruclions  produced  in  the  lymphatics,  leading 
from  the  part,  by  fchirrous  affedions  of  the  liver, 
fpleen,  and  other  abdominal  vifcera.  I  have  likewife 
known  it  induced  by  the  prelfure  of  a  trufs  applied 
for  the  cure  of  a  hernia.* 

When  the  fwelling  is  conne£led  with  anafarca  in 
other  parts,  it  is  thereby  fo  diftinclly  marked,  as  to 
render  a  particular  defcription  of  it  unnecefl'ary. 
When  it  takes  place  as  a  local  difeafe,  its  appearances 
are  thefe  :  a  colourlefs  tumor  in  the  courfe  of  the  fper* 

*  An  inftancc  of  this  is  alfo  mentioned  l>y  Doughs.  Treatife  on  the 
Hydrocele. 


I02  On  the  Hydrocele.  Chap.  XXIV. 

matic  cord ;  foft  and  inelaftic  to  the  feel,  and  not  at- 
tended with  fluctuation.  In  an  ered  pofture,  it  is  of 
an  oblong  figure,  but  when  the  body  is  in  a  recum- 
bent poflure,  it  becomes  flat.  It  does  not  commonly 
occupy  more  than  the  ufual  ftretch  of  the  cord  along 
the  groin,  but  occaiionally  it  extends  down  the  length 
of  the  tedicle,  and  even  flretches  the  fcroium  to  an 
enormous  fize.* 

By  preffure,  the  fwelHng  can  be  always  made  to  re- 
cede, never  entirely,  but  often  in  great  part,  into  the 
cavity  of  the  abdomen.  It  initantly,  however,  returns 
to  occupy  its  former  fituation  on  the  preifure  being 
withdrawn. 

When  the  tumor  is  connected  with  general  anafar- 
ca,  unlefs  the  caufe  which  gave  rife  to  the  difeafe  of 
the  conflitution  is  removed,  it  would  be  a  vain  attempt 
to  endeavour  to  cure  this  particular  fymptom.  And 
it  commonly  happens,  that  thefe  fwel lings  in  the  groin, 
arifmg  from  anaiarca,  difappear  when  the  difeafe  of 
the  fylf em  is  carried  off. 

But  when  the  fwelling  occurs  as  an  original  difeafe, 
produced,  perhaps,  by  fome  local  caufe  ;  a  local  re- 
medy is  then  the  bed  means  we  can  employ.  In  this 
cafe,  as  we  have  not  the  general  bad  habit  of  body  to 
encounter,  which  commonly  occurs  in  fcrotal  anafar- 
ca,  we  need  not  be  fo  much  afraid  of  making  a  free 
incifion  into  the  tumor ;  and  accordingly,  all  that  is 
neceffary  to  be  done  is  this  :  as  foon  as  the  tumor  has 
acquired  fuch  a  fize  as  to  become  inconvenient,  an 
incifion  Ihould  be  made  with  a  fcalpel  from  one  end 
of  it  to  the  other,  taking  care  to  go  fo  deep,  as  effec- 
tually to  difcharge  all  the  fluid  contained  in  the  cells 
of  the  part ;  and  as  the  ferum  is  fometimes  found  to 
Jiave  acquired  a  vifcid  confifl:ence,  this  circumftance 
renders  a  deep  incifion  more  neceffary  than  it  other- 
wife  would  be.     In  making  this  incifion,  we  have 

*  A  remarkable  inftance  of  this  is  related  by  Mr.  Pott,  who,  from  a 
fwelling  of  this  kind,  difcharged  eleven  Englifli  pints  at  once.  Treatife 
en  Hydrocele,  cafe  x. 


Se<a.  VI.  On  the  Hydrocele.  1 03 

chiefly  to  avoid  what  may  be  properly  termed  the  con- 
flituent  parts  of  the  fpermatic  cord,  the  fpermatic  ar- 
tery and  vein  and  vas  deferens,  and  which,  in  every 
inftance,  may  always  with  certainty  be  done. 

The  contents  of  the  fwelling  being  removed,  a 
pledget  of  foft  old  linen,  fpread  with  common  wax 
ointment,  fliould  be  inferted  between  the  lips  of  the 
fore,  which  mull:  afterwards  be  treated  as  a  fimple 
wound  from  any  other  caufe  ;  by  poultices  and  fo- 
mentations, if  much  pain  and  a  fcanty  fuppuration 
take  place  ;  and  by  due  attention  to  drefling,  fo  as  to 
induce  the  formation  of  firm  granulations  from  the 
bottom. 

In  fome  inftances,  a  cure  has  been  attempted  by 
making  deep  punclures  in  different  parts  of  the  tu- 
mor ;  but  while  they  do  not  with  fuch  certainty  re- 
move the  difeafe,  they  are  equally  painful  with  an  in- 
cifion  carried  the  full  length  of  the  tumor. 


SECTION     VI. 

Of  the  Encyjlcd  Hydrocele  of  the  Spermatic  Cord. 

THE  furrounding  fubftance  of  the  fpermatic  cord 
being  entirely  cellular,  the  formation  of  encyfl- 
ed  tumors,  v/e  may  conclude,  ought  occafionally  to 
take  place  here,  as  well  as  in  other  parts  of  the  body  ; 
and  accordingly  we  find,  in  fome  inftances,  that  wa- 
ter, inflcad  of  diffufing  itfelf  over  the  whole  fperma- 
tic procefs,  is  colleded  in  one  or  more  diftind;  cells 
or  cyfts. 

This  kind  of  hydrocele  being  on  its  firfl  appearance 
fmall,  gives  little  or  no  trouble,  and  is  therefore 
feldoni  much  noticed,  till  it  has  acquired  a  larger 
fize.  In  fome,  it  begins  in  the  fuperipr  part  of  the 
procefs  ;  but,  in  general,  it  is  firfl  perceived  towords 
the  lower  part  of  it,  a  little  above  the  epididymis.  By 


I04  On  the  Hydrocele,  Chap.  XXIV. 

degrees,  however,  it  ftretches  upwards,  and,  in  fome 
inllances,  fo  far  down  as  to  reach  from  the  abdomi- 
nal mufclcs  to  the  very  bottom  of  the  fcrotum ;  in 
which  cafe,  a  perfon  who  had  not  formerly  feen  the 
difeafe,  might  be  apt  to  miftake  it  for  a  hydrocele  of 
the  tunica  vaginalis.  But  we  have  a  very  certain  mark 
of  diftinftion  between  the  two  difeafes. 

In  the  commencement  of  this  variety  of  hydrocele, 
the  tumor  is  always  above  the  teflicle,  which  is  dif- 
tinftly  felt  below  ;  and  in  the  more  advanced  ftages 
of  the  difeafe,  the  teftis  is  found  at  the  back  part  of 
it.  Whereas,  in  the  advanced  ftate  of  a  hydrocele  of 
the  tunica  vaginalis,  although  fome  degree  of  hard- 
nefs  takes  place  where  the  tunica  vaginalis  adheres  to 
the  tefticle,  yet  v/hen  the  tumor  is  large,  the  teftis  can 
never  be  diltindly  felt.  In  the  encyfted  hydrocele  of 
the  cord,  the  figure  and  fize  of  the  penis  is  not  com- 
monly fo  much  altered,  as  when  the  water  is  collect- 
ed in  the  tunica  vaginalis,  in  which  the  penis  frequent- 
ly difappears  almoft  entirely. 

In  other  circumftances,  the  encyfted  dropfy  of  the 
fpermatic  cord,  is  very  fimilar  to  the  hydrocele  of  the 
tunica  vaginalis  teftis.  A  fiudluation  of  a  fluid  is  fen- 
fibly  difcovered  on  prelTure.  The  tumor  is  common- 
ly of  a  pyramidal  form,  which  is  alfo  the  cafe  with 
the  other,  with  its  bafe  or  largeft  extremity  down- 
ward.* And  no  preiTure  has  any  influence  in  mak- 
ing it  difappear,  either  altogether  or  in  part. 

This  is  the  appearance  of  the  tumor  when  the  wa- 
ter is  contained  in  one  cyft.  When  feparated  into 
two  diftincl  cells,  as  fometimes  happens,  the  line  of 
divifion  is  commonly  evident  by  the  tumor  being  at 
that  part  fomewhat  puckered,  or  diminiftied  in  its  di-» 
ameter.     A  fimilar  appearance  alfo  takes  place,  when 

*  A  hydrocele  of  the  tunica  vaginalis  teftis,  is  fo  frequently  Indeed  of 
a  pyramida,l  form,  with  its  bafe  downwards,  that  this  lliape  may  be  con- 
lidered  as  one  of  the  charaAeriftic  appearances  of  the  difeafe ;  every 
ether  tumor  to  which  the  teftis  and  its  coats  are  liable,  being  either  morf 
round,  or  of  a  more  irregular  fliape. 


Sc£l:.  VI.  On  the  Hydrocele,  105 

this  variety  of  hydrocele  is  combined  with  a  real  hy- 
drocele of  the  tunica  vaginalis  teftis,  which,  in  fome 
inflances,  happens  ;  and  in  this  cafe,  a  line  of  fepara- 
tion  may  be  obferved,  where  the  upper  extremity  of 
the  tunica  vaginalis  terminates. 

The  means  of  diftindion  between  this  fpecies  of  hy- 
drocele, and  that  of  the  vaginal  coat  of  the  teftis,  have 
already  been  mentioned.  The  only  other  tumors  with 
which  it  is  in  danger  of  being  confounded,  are,  the 
anafarcous  hydrocele  of  the  fpermatic  cord,  and  a  re- 
al hernia,  either  of  the  omentum,  or  of  a  portion  of 
gut.  From  the  former,  however,  as  alfo  from  an 
omental  hernia,  it  may  in  general  be  diftinguiflied.  In 
neither  of  thefe,  is  the  fluftuation  of  a  fluid  to  be  per- 
ceived, and  to  the  touch  they  are  both  foft  and  ine- 
laftic  ;  whereas,  in  this  variety  of  hydrocele,  the  tu- 
mor has  a  fpringy  kind  of  feeling,  and  a  fluftuation 
is  fcnfibly  found  in  it.  And  in  both  the  others,  the 
fwelling  in  fome  degree  recedes  upon  prefTure,  which 
it  never  does  in  this  variety  of  encyfted  hydrocele. 

From  a  hernia  of  any  portion  of  gut,  it  is  chiefly 
diftinguiflied  by  the  tumor  beginning,  not  at  the  ring 
of  the  external  oblique  mufcle,  as  is  the  cafe  in  her- 
nia, but  farther  down  the  cord.  In  the  latter,  the 
fwelling  commonly  becomes  lefs  on  the  patient  being 
placed  in  a  horizontal  poflure  ;  and  it  is  always  con- 
fiderably  afl'eded  both  by  coughing  and  faeezing  ;  but 
no  pofture,  no  preflure,  nor  any  accidental  circum- 
flance,  alters  the  fize  of  this  variety  of  hydrocele. 
The  abfence  of  the  fymptoms  of  hernia,  too,  is  here 
material  in  the  ^diftinction.  For  there  is  neither  pain 
in  the  tumor,  nor  in  the  abdomen  ;  nor  ficknefs,  vom- 
iting, nor  any  interruption  to  the  paflTage  by  ftool,  as 
very  commonly  happens  in  hernia. 

Although  all  the  ancient  writers  were  ignorant  of 
the  anatomy  of  the  parts  concerned  in  this  difeafe,  it 
is  evident  they  were  well  aware  of  its  exiftence.  We 
find  it  particularly  defcribed  by  ^gineta,  Albucafis, 
and  afterwards  by  Fallopius,  Wifeman,  and  others. 


io5  On  the  Hydrocele.  Chap.  XXIV. 

Amaud,  in  his  Treatife  on  Herniae,  alfo  takes  notice 
of  it,  though  not  with  much  accuracy  ;  and  we  find 
it  more  lately  defcribed  with  exactnefs  by  the  late  Dr. 
Monro,  by  Douglas,  and  by  Mr.  Pott. 

This  variety  of  hydrocele,  as  alfo  the  anafarcous 
fwelling  of  the  cord,  and  the  cedematous  tumor  of  the 
fcrotum,  are  all  frequent  in  infancy.  Thefe  tumors, 
however,  in  childhood,  fcldom  prove  permanent.  For 
the  mod  part,  they  readily  yield  to  gentle  friction  with 
volatile  liniment,  or  any  other  flimulating  or  aftringent 
application  ;  fuch  as  fpirit  of  wine,  a  ftrong  folution 
of  alum  in  water,  or  of  crude  fal  ammoniac  in  vine- 
gar. The  late  Dr.  Monro  advifes  the  application  of 
cloths  warmed  with  the  fumes  of  burning  benzoin. 

Even  the  hydrocele  of  the  tunica  vaginalis  fometimes 
occurs  in  early  life.  I  have  met  with  different  inftan- 
ces  of  it  in  children  under  three  years  of  age  ;  but  it 
is  not  fo  readily  aded  upon  by  the  external  applica- 
tion of  ftimulants,  as  the  anafarcous  hydrocele. 

Whether  in  children  or  adults,  when  this  variety  of 
tumor  becomes  large,  we  employ  either  the  means  for 
a  palliative,  or  a  radical  cure,  as  have  been  already 
advifed  in  the  hydrocele  of  the  tunica  vaginalis  teflis. 

When  it  is  our  intention  merely  to  difcharge  the 
water  by  a  punfture,  it  fhould  be  done  with  a  trocar, 
in  the  fame  manner  as  was  directed  in  Section  III.  for 
a  hydrocele  of  the  tunica  vaginalis ;  taking  care  to  in- 
troduce the  inflrument  at  the  mod  depending  part  of 
the  tumor.  And  again,  when  we  mean  to  accomplifli 
a  radical  cure,  the  fame  means  are  to  be  employed, 
that  have  been  already  advifed  for  the  radical  cure  of 
that  variety  of  the  difeafe  in  the  tunica  vaginalis  teflis. 
The  fame  objedtions  indeed  do  not  here  occur  to  the 
ufe  of  the  feton,  as  in  the  hydrocele  of  the  tunica  va^ 
ginalis,  from  the  prefence  of  the  teflis.  And  if  we 
could,  in  every  fpecies  of  hydrocele,  afcertain  the  ex- 
afl:  contents  of  the  tumor,  the  feton  might,  no  doubt, 
be  here  employed  with  fafety  and  advantage.  But,  as 
i.t  is  obvious,  from  what  I  have  already  had  occafiou 


Se^t.  VI.  On  the  Hydrccele,  toy 

to  remark,  that  no  certainty  of  this  can  at  all  times  be 
obtained  ;  and,  as  the  hydrocele  of  a  hernial  fac,  in 
which  a  portion  of  gut  is  contained,  may  be  as  readi- 
ly confounded  with  this  as  with  any  other  fpecies  of 
the  difeafe,  I  would  therefore,  even  in  the  hydrocele 
of  the  cord,  lay  this  method  of  cure  entirely  afide. 

An  objedion  occurs,  in  this  variety  of  the  diieafe, 
to  the  method  of  cure  by  cauitic,  which  is  not  appli- 
cable in  the  hydrocele  of  the  tunica  vai^nnalis  teltis. 
The  ferum,  hi  fome  inflances,  is  collected  in  two  or 
more  cyfts  ;  different  cafes  of  which  I  have  met  with  ; 
and  nniilar  inflances  of  it  are  related  by  Garengeot, 
Doui^las,  and  others.  Now,  in  this  fituation,  if  cauf- 
tic  fhould  be  applied  in  the  method  recommended  by 
Mr.  Elfe,  upon  a  fmall  fpot  only,  all  the  water  would 
not  be  difcharged  ;  and,  in  order  to  obtain  a  complete 
removal  of  the  difeafe,  it  would  be  necefl'ary  to  repeat 
the  application  of  the  cauftic  to  every  cyft  in  v^'hich  fe- 
rum might  be  colletled. 

This,  I  think,  is  an  additional  reafon  for  our  giving 
a  general  preference  to  the  method  of  cure  by  inci- 
fion  ;  which,  by  laying  the  tumor  open  from  one  end 
to  the  other,  divides  at  once  all  the  different  cyfts  of 
wliich  it  may  be  compofed,  and  faves  the  patient  from 
that  diftrefs  and  difappointment  which  mufl  always  be 
experienced,  on  a  complete  cure  not  being  obtained, 
when  good  reafons  had  been  previoufly  given  for  ex- 
peding  it.  I  would  therefore  advife  the  treatment  by 
incifion  to  be  preferred  in  this  fpecies  of  hydrocele, 
as  I  have  done  already  in  the  hydrocele  of  the  tunica 
vaginalis  ;  and  the  mode  of  performing  the  operation, 
and  the  after  treatment  of  the  patient,  are  nearly  the 
fame  in  each. 

I  have  thus  enumerated  every  hydrocele  that  can 
be  properly  confidered  as  forming  a  diftinft  variety 
of  the  difeafe.  In  doing  fo,  as  I  have  defcribed  no  tu- 
mor but  fuch  as  every  pradlitioner  of  experience  mufl 
have  met  with,  and  of  which  the  fymptoms  are  clear- 


lo8  On  the  Hydrocele.  Chap.  XXIV. 

ly  and  diftin6lly  marked,  fo  it  will  not,  I  hope,  be  con- 
fidered  as  an  unneceflary  degree  of  minutenefs,  that  I 
have  particularly  taken  notice  of  them  all. 

I  can  by  no  means  agree  with  fome  authors,  partic- 
ularly with  Mr.  Sharpe*  and  Mr.  Elfe,  who  think  that 
it  might  be  better  to  confine  the  defcription  of  hydro- 
cele to  two  varieties.  We  need  not  indeed  wonder  at 
Mr.  Sharpe  fpeaking  in  this  manner  ;  for,  even  at  the 
late  period  in  which  he  wrote,  although  the  exiftence 
of  all  the  varieties  of  the  difeafe  that  I  have  mention- 
ed had  been  defcribed  by  different  authors,  yet  they 
"were  not  underllood  with  much  accuracy  ;  and  it  is 
evident  from  Mr.  Sharpens  writings  on  the  fubjeft, 
that  his  ideas  of  them  were  in  many  refpecls  more 
confuted  than  might  have  been  expetied  in  one  of  his 
ufaal  accuracy  and  penetration.  But,  whatever  was 
the  cafe  with  Mr.  Sharpe,  it  is  truly  furprifmg, 
that  thofe  who  are  unqueflionably  well  informed  in 
every  circumftance  relating  to  this  difeafe,  and  who 
muft  be  convinced,  from  frequent  diffe6lions,  of  the 
exiftence  of  all  the  varieties  that  I  have  been  mention- 
ing, ihould  obje£l  to  their  being  retained.  Where  no 
evident  or  marked  diftin£lion  occurs  between  one  tu- 
mor and  another,  an  attempt  to  eftablifh  a  difference 
would  be  ufelefs,  and  therefore  improper ;  but  where 
appearances  point  out  an  obvious  variety,  it  would 
furely  be  confidered  as  much  want  of  accuracy  in  an 
author  to  omit  the  detail  of  them. 

In  the  defcription  that  I  have  given  of  the  five  dif- 
ferent fpecies  of  hydrocele,  to  wit,  the  anafarcous 
fwelling  of  the  fcrotum,  the  hydrocele  of  the  tunica 
vaginalis  teftis,  the  hydrocele  of  the  hernial  fac,  the 
anafarcous  and  the  encyfted  hydrocele  of  the  fperma- 
tic  cord,  it  was  neceffary  to  enumerate  the  fymptoms 
of  each,  as  they  occur  feparately  and  uncombined.  It 
fometimes  happens,  however,  that  one,  two,  or  more 
of  the  different  varieties  occur  at  the  fame  time  in  the 

*  Trcatife  on  the  OperatioBS  of  Surjcrj-, 


Sed.  VL  On  the  Hydrocele.  1 09 

fame  patient.  I  have  met  with  inftances  of  three,  and 
not  unfrequently  with  two  varieties  in  the  fame  perfon. 
The  late  Dr.  Monro  mentions  an  inftance  of  four  fpe- 
cies  of  hydrocele  being  all  combined  in  one  cafe.* 

In  fuch  cafes,  fome  difficulty  and  confufion  is,  no 
doubt,  to  be  expeded ;  but  praftitioners,  in  forming 
a  judgment  of  their  nature,  mufl  be  entirely  direfted 
by  due  attention  to  the  various  fymptoms  which  take 
place  in  each  variety  of  the  difeafe,  when  met  with 
feparately,  and  unconnefted  with  others. 

We  now  proceed  to  the  confideration  of  the  other 
varieties  of  falfe  hernia  ;  and  firll  of  the  hsematocele. 

•  vide  Monro's  Works,  4to.  p.  576. 


iia  On  the  Hamaiocele.        Chap.  XXV, 


CHAPTER     XXV. 


ON  THE  HEMATOCELE. 

THE  hsematocele  is  a  tumor  in  the  fcrotum  or  fper- 
matic  cord,  produced  by  extravafated  blood. 

The  ufual  feat  of  this  difeafe  is  in  the  tunica  vagi- 
nalis of  the  teftis  ;  but,  in  fome  inllances,  it  is  feated 
in  the  fpermatic  procefs,  and  occafionally  it  is  met  with 
in  the  dartos. 

The  hsematocele  always  arifes  from  the  rupture  or 
divifion  of  one  or  more  blood  vcfiels,  and  it  is  mofl 
frequently  the  eife£t  of  external  violence.  Blows  up- 
on the  fcrotum,  and  bruifes  received  in  riding,  fome- 
times  burft  the  veins,  not  only  in  the  cellular  fubflance 
of  the  fcrotum,  but  in  the  vaginal  coat  of  the  tefticle. 
Accidents  of  a  fimilar  nature  have  produced  fimilar 
affections  in  the  courfe  of  the  fpermatic  cord  ;  and,  as 
the  parts  in  this  fituation  are  foft  and  cellular,  the  rup- 
ture either  of  an  artery,  or  a  vein  of  any  confiderable 
fize,  is,  for  the  mofl  part,  attended  with  a  plentiful  ex- 
travafation  of  their  contents. 

In  the  tunica  vaginalis  teftis,  a  hasmatocele  is  fome- 
times  induced  by  the  point  of  a  trocar,  or  of  a  lancet, 
in  tapping  for  a  hydrocele,  wounding  fome  of  the 
blood  veffels  of  the  fac,  which,  in  fuch  cafes,  are  com- 
monly enlarged. 

We  become  certain  of  what  has  happened,  by  the 
ferum,  as  it  runs  off,  being  fuddenly  tinged  with  blood  ; 
but,  in  fome  inffances,  this  does  not  appear  till  the  col- 
lection is  all  difcharged,  when  the  firft  intimation  we 
receive  of  it  is  by  the  fudden  appearance  of  a  tumor 
in  the  fite  of  the  hydrocele.  I  have  now  met  with  va- 
rious inflances  of  this,  in  all  of  which  the  tumor  pro- 
duced by  the  extravafated  blood  arrived  at  a  very  con- 
fiderable height  in  the  courfe  of  a  few  hours. 


Chap.  XXV.         On  the  Hamaiocele*  1 1 1 

In  fome,  the  difeafe  is  produced  in  a  different  man- 
ner. Where  the  quantity  of  ferum  has  been  large, 
the  fudden  difcharge  of  it,  by  taking  aw  ay  the  fupport 
which  the  velfels  have  been  accuftonied  to  receive  from 
it,  is  not  unfrequently  the  cauie  of  the  rupture  of  foine 
of  them  ;  and,  from  repeated  obfervation,  I  think  it 
may  be  confidered  as  certain,  that  whenever  a  large 
tumor  is  produced  fuddenly,  that  is,  in  the  courfe  of 
an  hour  or  two,  either  in  the  fcrotum,  or  fpermatic 
cord,  after  the  contents  of  a  hydrocele  have  been  dif- 
charged  by  tapping,  that  it  arifes  entirely  from  extra- 
vafated  blood  ;  for  collections  of  water  are  never  known 
fo  quickly  to  become  large. 

In  the  fpermatic  procefs,  injuries  of  the  fame  kind 
will  be  attended  with  a  hmilar  effetb  upon  the  fmall 
veins  of  the  fac  containing  the  water  ;  and  more  con- 
fiderable  violence  has,  in  fome  inftances  produced  a 
rupture  of  the  fpermatic  artery  and  vein. 

But  in  whatever  way  the  tumor  has  been  produced, 
the  appearances  are  nearly  fimilar  to  thofe  of  watery 
colledions  in  the  fame  parts  ;  fo  that  it  is  not  neceffa- 
ry  to  repeat  them  here  ;  only  it  may  be  remarked, 
that,  when  blood  is  extravafated  in  the  cellular  fub- 
ftance  of  the  fcrotum,  it  is  eafily  diflinguifiied  from  a 
collection  of  water  by  the  colour,  as  it  affumes  all  the 
ufual  appearances  of  an  echymofis.  When  the  col- 
lection is  feated  in  the  tunica  vaginalis,  the  means  of 
diltindion  are  not  fo  obvious  ;  but  I  may  remark,  that 
a  tumor  produced  by  blood  is  heavier  than  one  of  the 
fame  fize  produced  by  water  ;  and  pradlitioners,  much 
accuftomed  to  handle  thefe  fwelhngs,  can  in  fome  in- 
ftances judge  of  their  contents  from  their  confidence, 
by  the  difference  which  this  gives  to  manual  exami- 
nation. 

The  treatment  of  this  kind  of  tumor,  is  nearly  the 
fame  with  that  which  I  have  advifcd  in  Seel.  IV.  Chap. 
XXIV.  In  the  commencement  of  the  anafarcous  or 
diilufed  hasmatocele,  when  produced  by  external  vio- 
lence, whether  in  the  fcrotum  or  fpermatic  procefs. 


112  On  the  Hamatoccle.         Chap.  XXV. 

the  application  of  ardent  fpirits,  a  folution  of  alum, 
volatile  liniment,  or  a  ftrong  folution  of  fal  ammoniac 
in  vinegar,  will,  in  fome  instances,  remove  it.  But, 
when  this  does  not  fucceed,  and  efpecially  if  the  tu- 
mor acquires  a  greater  bulk,  it  mufl,  in  that  cafe,  be 
laid  open,  and,  in  every  refpeft,  treated  in  the  fame 
manner  as  has  been  already  directed  for  the  hydrocele  ; 
only  I  may  remark,  that,  if  a  ruptured  blood  veflel  is 
difcovered,  the  only  effectual  means  of  preventing  a 
return  of  the  tumor,  is  to  fecure  it  with  a  ligature. 

In  like  manner,  all  colledions  of  blood,  whether  in 
the  vaginal  coat  of  the  teftis,  or  in  the  cyft  of  a  form- 
er hydrocele  of  the  fpermatic  cord,  are  to  be  laid  op- 
en by  an  incifion,  extending  the  whole  length  of  the 
tumor,  and,  in  other  refpefts,  treated  exaftly  as  I  have 
advifed  in  the  fourth  feftion  of  the  preceding  chapter, 
for  a  hydrocele.  And  I  need  fcarcely  oblerve,  that, 
if  any  ruptured  veffel  comes  in  view  in  the  courfe  of 
the  operation,  it  ought  to  be  immediately  fecured  with 
a  ligature :  otherwife  a  conftant  difcharge  of  blood 
may  be  looked  for  during  the  cure  ;  the  patient  will 
be  thereby  much  incommoded  and  weakened,  and  the 
cure  unneceflarily  protrafted. 

It  fometimes  happens,  however,  whether  the  difeafe 
is  feated  in  the  fpermatic  procefs,  or  tunica  vaginalis 
teftis,  that  the  veffels  from  whence  the  blood  is  dif- 
charged  cannot  be  difcovered  ;  a  very  confiderable 
oozing,  continuing  from  day  to  day,  notwithftanding 
the  ufe  of  bark,  vitriolic  acid,  and  every  other  means 
that  are  commonly  employed.  As  patients  in  this  fit- 
uation  foon  become  weak  and  emaciated,  one  great 
object  of  the  practitioner  is  to  fupport  them  with  nour- 
ifhing  food.  A  moderate  allowance  of  animal  food 
proves  always  ufeful ;  nor  is  it  found  that  a  liberal  ufe 
of  wine  does  harm.  In  fome  inftances,  I  have  even 
thought  that  it  tended  to  leifen  the  difcharge. 

I  have  uniformly,  however,  found,  that  local  rem- 
edies prove  chiefly  ufeful,  particularly  the  application 
of  ardent  fpirits,  ether,  or  tindure  of  myrrh,  to  the 


Chap.  XXV.         On  the  Ha?natocele,  113 

furface  of  the  fore :  pledgets  of  foft  liiit,  foaked  in 
one  or  other  of  thefe,  and  renewed  from  time  to  time, 
not  only  ferve  to  check  the  difcharge  of  blood,  but 
tend,  for  the  moll  part,  to  promote  the  formation  of 
good  matter. 

In  fome  inftances,  however,  all  our  endeavours  fail, 
and  the  patient  contiiming  to  lofe  ground  daily,  we 
are  warranted  in  advifing  any  meafure  that  may  pro- 
bably tend  to  fave  him.  In  fuch  circumflances,  the 
extirpation  of  the  teflicle  has  been  advifcd.  At  one 
time,  I  was  induced  to  think  favourably  of  this  mea- 
fure ;  but  further  experience  has  not  fhown,  that 
much  dependence  is  to  be  placed  on  it.  At  leafl:,  in 
two  cafes,  in  which  it  was  put  in  practice,  no  advan- 
tage was  derived  from  it ;  while,  in  both,  it  was  the 
caufe  of  much  additional  diftrefs.  I  do  not  therefore 
mean  ever  to  advifc  it  again. 

Another  variety  of  tumor  produced  by  blood  is 
mentioned  by  Mr.  Pott,  in  which  the  blood  is  con- 
tained within  the  tunica  albuginea  of  the  teftis.  It 
proceeds,  he  thinks,  from  a  relaxation  or  diflblution 
of  part  of  the  vafcular  ftru£lure  of  the  tefticle  ;  and, 
when  the  quantity  of  blood  coUeded  is  confiderable, 
it  produces,  Mr.  Pott  remarks,  a  fludtuation  fome- 
what  like  to  that  of  a  hydrocele  of  the  tunica  vagi- 
nalis. 

When  this  is  miftaken  for  a  hydrocele,  as  it  has 
fometimes  been,  and  an  opening  with  a  trocar  is  made 
in  it,  a  difcharge  is  produced,  of  a  dark  duflvy  colour- 
ed blood,  nearly  of  the  confidence  of  thin  chocolate  ; 
but  the  diminution  of  the  tumor,  by  this  evacuation, 
is  feldom  confiderable. 

The  perforation,  therefore,  made  in  it  with  the  tro- 
car does  no  good ;  and  as  the  teflicle  is  commonly  fo 
far  fpoiled  by  the  difeafe  as  to  be  rendered  entirely 
ufelefs,  caflration  is  advifed  as  the  befl  remedy.* 

•  Pott's  Trcatife  on  the  Hydrocele. 

Vol.  hi.  I 


114  Onihe  Hcemaiccek*        Chap.  XXV* 

I  have  different  times  met  with  a  difeafe  very  fimi-' 
lar  to  this  defcribed  by  Mr.  Pott :  but  as  the  blood 
in  fuch  inftances  did  not  appear  to  be  extravafated^ 
but  to  be  ftill  contained  in  the  veiTels  of  the  teftis,  in 
an  enlarged  varicofe  ftate,  I  am  not  inclined,  there- 
fore, to  refer  this  kind  of  tumor  to  any  jpecies  of  ha^- 
matocele,  but  rather  to  confider  it  as  a  variety  of  va- 
rix.  I  have  even  feen  this  variety  of  tumor  miftaken 
for  a  hydrocele,  and  treated  as  fuch,  by  a  trocar  be- 
ing plunged  into  it,  when  the  effects  were  exaftly 
what  are  defcribed  by  Mr.  Pott.  But,  if  the  blood 
had  been  extravafated,  a  more  copious  difcharge 
would  have  taken  place  from  the  perforation,  than 
was  obtained  by  it  in  any  of  the  cafes  to  which  I  al- 
lude. Even  where  the  tumor  has  been  of  a  confide- 
rable  fize,  I  never  found  it  pofTible  to  evacuate  in  this 
manner  more  than  a  fpoonful  or  two  of  blood,  and 
although,  in  fuch  cafes,  the  blood  appears  evidently 
more  vifcid  than  in  a  flate  of  health,  this  is  not  in  fuch 
a  degree  as  ought  to  prevent  it  from  being  freely  dif- 
charged  by  the  canula  of  a  trocar,  were  it  lodged  in 
a  flate  of  extravafation. 

In  all  the  cafes  that  I  have  feen  of  this  tumor,  when 
it  was  not  opened,  but  merely  fupported  by  a  fufpen- 
fory  bag,  it  has  remained  indolent  and  ftationary  for 
many  years.  But  whenever  it  has  been  touched  with 
an  inflrument  in  order  to  difcharge  its  contents,  it  has 
from  that  moment  gone  wrong.  The  patient  who 
had  fuffered  little  previous  pain,  foon  became  greatly 
diftrefsed  ;  the  fwelling  then  began  to  increafe  ;  fepa- 
rate  encyfted  collections  formed  in  it ;  thefe  at  lafl 
burfl  and  left  an  ugly  fore  of  an  unequal  furface,  and  a 
putrefcent  bloody  difcharge,  on  which  no  application 
had  any  effect ;  {o  that  caftration  at  lafl  became  necefla- 
ry.  Even  this  dCes  not  always  afford  relief ;  for,  infome 
inflances,  fuch  a  fpongy  relaxed  flate  of  the  veffels 
takes  place  along  the  vv'hole  courfe  of  the  cord,  that, 
though  they  are  fecured  with  ligatures  to-day,  blood 
burlts  out  at  different  parts  to-morrow.     Of  this  I 


chap.  XXV.        On  fhe  Hamatocek»  115 

was  once  concerned  in  a  very  diftrefsful  inftance.  Af- 
ter the  ufual  operation  of  caftration,  frelh  hsemorrha- 
gies  occurred  at  every  dreffing ;  the  veflcls  were  at 
different  times  fecured  with  ligatures,  but  to  no  pur- 
pofe ;  the  blood  burft  out  again  and  again  ;  and  the 
patient,  after  flfte^^g  much  diitrcfs  from  this  caufc 
alone,  at  laft  died. 

The  chief  differences  which,  before  laying  the  parts 
open,  can  be  obferved  between  this  variety  of  tumor 
and  a  hydrocele  of  the  tunica  vaginalis,  is,  that  in 
this,  the  fluduation  is  never  fo  evident  as  in  the  oth- 
er ;  the  tumor  is  heavy  in  proportion  to  its  fize ;  the 
form  not  fo  pyramidal  as  that  of  a  hydrocele  ;  and  if 
properly  fupported  with  a  bandage,  it  does  not  receive 
any  additional  increafe.  Whenever  thefe  circumftan- 
ces,  therefore,  occur  in  the  fame  cafe,  they  give  much 
reafon  to  fufpect,  that  the  difeafe  is  of  this  kind  j  and 
therefore,  that  no  operation  fliould  be  advifed.  The 
patient  (hould  be  deHred  to  trufl  entirely  to  a  \Me\\ 
adapted  fufpenfory  bag  ;  to  avoid  fevere  fatigue  ;  and 
to  prevent  a  coftlve  flate  of  the  bowels,  which  in  all 
difeafes  of  thefe  parts,  very  conflantly  does  harm. 


M 


n6  Of  the  Varicocele,  "^c.        Chap.  XX VL 


CHATTER     XXVI. 


OF  THE   VARICOCELE,  CIRCOCEI^JE,  »ERMATOCELE, 
AND    PNEUMATOCELE. 


BY  the  term  varicocele,  is  meant  a  varicofe  diflen- 
tion  of  the  veins  of  the  fcrotum,  which  in  this 
flate  form  a  tumor  of  hard  knotty  inequalities,  feldom 
attended  with  pain,  and  commonly  productive  of  no 
inconvenience,  if  it  be  not  from  its  bulk. 

The  circocele  is  a  tumor  of  the  fpermatic  'cord,  ex- 
tending from  the  fuperior  part  of  the  fcrotum  to  the 
abdominal  mufcles,  and  is  produced  by  a  varicofe  dif- 
tention  of  the  fpermatic  vein. 

Thefe  tumors  are  occafionally  produced  by  preflure 
on  the  courfe  of  the  veins ;  but  we  are  feldom  able 
to  dillinguifh  the  caufe  of  it,  in  which  cafe,  we  con- 
clude, that  they  arife  from  debility  or  relaxation  in  the 
veflels  in  which  they  occur. 

When  tumors  in  the  courfe  of  the  veins  are  per- 
ceived to  give  rife  to  thefe  tumors,  or  when  the  pref- 
fure  of  a  hernial  trufs  upon  the  fpermatic  cord  appears 
to  have  produced  them,  the  removal  of  this  evident 
caufe  of  the  difeafe,  fhould  be  the  firfl  attempt  towards 
a  cure. 

When  produced  b]''  the  prefTure  of  a  trufs,  or  of 
any  other  fimilar  caufe,  an  alteration  in  the  bandage 
will  fometimes  remove  them.  When  the  prefTure  of 
fchirrous  tumors  give  rife  to  them.,  thefe  muft  be  ex- 
tirpated when  it  can  be  done  w-ith  fafety ;  and  when 
produced  by  tumors  tending  to  fuppurate,  warm  emol- 
lient applications  will  be  the  moft  ufeful  remedy. 

But  v/hen  a  general  relaxed  ft  ate  of  the  veins  ap- 
pears to  be  the  caufe  of  their  diftention,  fuch  reme- 
dies fhould  be  employed  as  will  moft  elfedually  re- 


Chap.  XXVI.       Of  the  Varicocele^  ^c,  117 

cover  that  tone  of  which-  they  have  been  deprived  by 
the  long  continuance  of  the  difeafe.  With  this  view, 
nothing  commonly  anfwers  fo  well  as  the  ufe  of  a 
proper  fufpenfory  banth/^,  and  the  application  of  a 
folution  of  alum,  a  foluiion  of  crude  fal  ammoniac  in 
vinegar,  and  other  aflringents,  to  the  parts  affefted. 

By  due  attention  to  this  kind  of  management,  the 
increafe  of  ahnofl  every  tumor  depending  upon  this 
caufe,  may  be  prevented ;  and  fo  much  relief  will  be 
thereby  obtained,  as  to  render  the  harfh  remedies  of 
the  knife,  the  cautery,  and  ligature,  recommended  by 
ancient  writers  for  the  removal  of  thefe  tumors,  alto- 
gether unneceflary. 

By  the  fpermatocele,  is  meant,  a  morbid  diftention 
of  the  epididymis  and  vas  deferens,  produced,  as  is 
fuppofed,  by  a  ftagnation  of  femen.  This  may  arife 
from  tumors,  ftridure,  or  inflammation  about  the 
caput  gallinaginis,  or  in  the  courfe  of  the  vas  defer- 
ens ;  but  there  is  reafon  to  think,  that  it  is  mod  fre- 
quently induced  by  inflammation. 

When  produced  by  Inflammation,  general  and  top- 
ical bloodletting,  gentle  laxatives,  a  low  cooling  diet, 
and  refl  of  body,  will  commonly  prove  the  mofl:  ufe- 
ful  remedies,  and  of  thefe  none  are  more  to  be  truft- 
ed  than  topical  bloodletting  with  leeches  which  fliould 
be  repeated  from  time  to  time,  according  to  the  ur- 
gency of  fymptoms.  And  again,  when  tumors 
are  difcovered  to  prefs  upon  the  vas  deferens,  they 
(liould  cither  be,  brought  to  fuppurate,  or  removed 
with  the  fcalpel,  when  it  can  be  done  with  fafcty. 
At  other  times  thefe  tumors  are  conneded  with  lues 
venerea ;  in  which  cafe,  a  well  directed  courfe  of 
mercury  will  be  moft  likely  to  anfwer. 

By  fome  we  are  told,  that  all  the  other  means  hav- 
ing failed,  caftration  has  at  lafl:  been  found  requifite. 

This,  however,  I  can  fcarcely  fuppofe  to  be  necef- 
fary  in  any  cafe ;  at  lead  I  never  met  with  an  inftance 
of  its  being  fo. 


118  Of  the  Varicocele,  ^c.       Chap.  XXVI. 

The  term  pneumatocele,  is  applied  to  fignify  a  dif- 
tention  of  the  fcrotum  by  a  colledion  of  air. 

This  has  been  defcribed  by  mod  of  the  ancient 
writers  as  a  frequent  occurrence ;  but  there  is  much 
reafon  to  think,  that  a  great  proportion  of  all  the  tu- 
mors which  they  defcribe  as  containing  air,  were  eith- 
er formed  by  colleftions  of  water,  or  by  the  protru- 
lion  of  fome  of  the  bowels.  That  fpecies  of  hernia 
to  which  young  children  are  liable,  is  to  this  day,  by 
our  common  people,  termed  a  wind  rupture,  as  is  the 
cafe  with  all  thofe  collections  of  water  m  the  fcrotum, 
"with  which  new  born  infants  are  aiTected.  But  we 
know  well,  that  none  of  thefe  tumors  are  formed  by 
air ;  and  that  their  contents  are  of  a  very  different 
pature. 

In  wounds  of  the  lungs,  air  Is  fometimes  thrown 
into  the  furrounding  cellular  fubftance,  and  in  that 
way  pafles  into  the  fcrotum,  as  it  does  in  particular 
inftances  over  the  whole  body ;  and  in  high  degrees 
of  putrid  difeafes,  fo  much  air  may  be  feparated  from 
the  blood,  as  to  diftend  the  cellular  fubftance  of  the 
fcrotum,  as  well  as  of  other  parts.  But  a  real  pneu- 
matocele has  never  probably  exifted  as  a  mere  local 
affection  of  the  fcrotum  ;  at  leaft  I  have  never  feen  it. 

In  the  cafe  of  air  fpreading  to  the  cellular  fubftance 
of  thefe  parts,  as  a  confequence  of  a  wound  of  the 
lungs,  the  fame  remedy  proves  eifeclual  that  we  em- 
ploy for  anafarcous  fweUings  formed  by  water,  to  wit, 
fmall  punctures  with  the  point  of  a  lancet,  which  are 
found  to  be  fufficient  for  difcharging  great  quantities 
of  air.  But  whenever  the  difeafe  is  induced  by  fuch 
a  degree  of  putrefcency  in  the  fyftem,  as  excites  a  fe- 
paration  of  air  from  the  blood,  there  can  be  little  rear 
Jon  to  look  for  advantage  from  any  means  that  qaii 
be  employed. 


Chap.  XX VII.         Of  the  Sarcocek.  1 1 9 

CHAPTER     XXVII, 

OF  THE  SARCOCELB,  OR  SCHIRROUS  TESTICLE, 


THE  term  farcocele,  Implies  a  firm  flefliy  enlarge- 
ment of  the  tefticle  :  a  fimple  inflammatory 
fwelHng  of  the  teflis  affords  a  tumor  of  fome  degree 
of  firmnefs ;  but  the  true  farcocele,  or  fchirrous  tefti- 
cle, is  attended  with  a  hardnefs  altogether  unufual  in 
the  real  hernia  humoralis,  or  inflamed  tefticle. 

A  fchirrous  tefticle,  in  the  courfe  of  its  progrefs, 
puts  on  fuch  a  variety  of  appearances,  as  renders  it 
difficult,  by  defcription,  to  give  an  adequate  idea  of  it. 
In  general,  however,  the  accefllon  and  progrefs  of  the 
difeafe  is  this  : 

An  unufual  degree  of  hardnefs,  attended  with  fome 
enlargement  of  the  teftis,  is  the  firft  indication  of  the 
difeafe.  The  parts  are  not  at  firft  difcoloured,  nor  is 
there  any  material  degree  of  pain.  In  a  gradual  man- 
ner, the  tumor  acquires  a  larger  fize.  At  firft,  it  is 
fmooth  and  equal,  but  on  becoming  larger,  it  alfo  be- 
comes harder  and  knotty  or  unequal  on  the  furface  : 
flight  pains  are  felt  in  every  part  of  it ;  and  if  it  be 
not  fufpendcd,  the  patient  complains  of  iineafmefs  in 
his  back. 

When  the  conftitution  Is  found,  the  difeafe  will  oc- 
cafionally  remain  in  this  fituation  for  a  great  length 
of  time  ;  and  in  fome  inftances,  by  moderate  diet, 
keeping  an  open  belly,  fufpending  the  tumor  proper- 
ly, and  avoiding  violent  exercife,  it  has  not  only  been 
prevented  from  increafing,  but,  in  a  gradual  manner, 
has  been  difcuffed.  This  favourable  termination, 
however,  it  muft  be  owned,  is  exceedingly  rare ;  for 
inftead  of  remaining  ftationary,  the  difeafe  in  general 
becomes  worfe.     It  acquires  a  larger  fize  j  becomes 


i  20  0/  the  Sarcocck.        Chap.  XXVII. 

ragged,  and  more  unequal  on  its  furface  ;  and  the 
pain,  which  at  firfh  was  trifling,  becomes  more  fevere, 
darting,  in  fmart  flings,  through  every  part  of  the 
tumor. 

The  inequalities  on  the  furface  of  the  tumor  by  de- 
grees increaie.  In  fome  inflances,  a  confiderable 
quantity  of  ferum  is  extravafated  into  the  tunica  vagi- 
nalis, which,  to  thofe  who  are  not  verfant  in  the  treat- 
ment of  difeafes  of  this  kind,  gives  the  tumor  the  ap- 
pearance of  a  common  hydrocele  ;  and  at  other  times,, 
inflead  of  fuch  depofitions  into  the  vaginal  coat  of  the 
tefticle,  partial  collections  of  matter  take  place  through 
the  whole  body  of  the  tumor.  Thefe  by  degrees  in- 
creafe,  and  the  fcrotum,  which  till  then  had  been  gra- 
dually diftending,  at  laft  burfts,  and  a  difcharge  takes 
place  from  the  various  collections  in  the  body  of  the 
tumor,  of  a  thin,  fetid,  bloody  matter. 

In  fome  inltances,  the  fpermatic  cord  becomes  hard 
and  enlarged  foon  after  the  commencement  of  the  dif- 
eafe  ;  but  this  does  not  commonly  happen  till  the  tu- 
mor has  acquired  a  confiderable  fize,  and  moll  fre- 
quently, I  have  obferved,  not  till  matter  has  formed 
in  it. 

On  the  teflis  increafmg  In  bulk,  this  afTedion  of 
the  cord  alfo  becomes  worfe.  From  being  at  hril  on- 
ly nightly  tumefied,  it  gradually  turns  more  hard  and 
fwelled  ;  it  becomes  fo  painful,  that  the  patient  can- 
not bear  to  be  touched,  and  knotty  or  unequal 
through  the  whole  extent  of  it. 

The  difcharge  from  the  openings  in  the  fcrotum 
flill  continues ;  but  although  the  quantity  of  matter 
is  increafed,  the  fize  of  the  tumor  is  not  thereby  di- 
minifiied.  It  rather  continues  indeed  to  increafe,  the 
edges  of  the  fore  become  hard,  Hvid,  and  retorted, 
and  fungous  excrefcences  pulh  out  from  different 
parts  of  it. 

Whatever  was  the  flate  of  the  patient's  health  on 
the  firft  attack  of  the  difeafe,  in  this  advanced  ftate  of 
it,  it  is  always  much  impaired.     He  now  becomes 


Chap.  XXVII.         Of  the  Sarcocele,  1 2 1 

emaciated,  of  a  pale,  wan  complexion,  and  the  difeafe, 
which  in  this  ftage,  is  a  real  cancer  of  the  moll  ma- 
lignant nature,  turning  dill  more  virulent,  by  the  pain 
becoming  more  tormenting,  the  patient  is  at  laft  car- 
ried otf  in  much  mifery. 

Such,  in  general,  is  the  progrefs  and  event  of  this 
dreadful  difeafe,  if  not  interrupted  by  the  extirpation 
of  the  teftis,  before  it  has  gone  too  far.  I  have  alrea- 
dy obferved,  that  it  exhibits  a  great  variety  of  fymp- 
touis.  Thofe  I  have  enumerated  occur  moft  fre- 
quentlv ;  but  no  defcription  cim  convey  a  clear  idea 
of  all  the  appearances  tliat  it  aifumcs. 

In  fome,  as  I  have  obferved  above,  it  remains  ap- 
parently in  an  indolent  inaftive  ftate,  for  a  great 
length  of  time,  even  for  years  ;  and  in  others,  it  pro- 
ceeds fo  rapidly,  that  in  the  fpace  of  a  few  months,  I 
have  known  it  pafs  through  all  the  changes  I  have 
enumerated. 

Nor  is  any  age,  temperament,  or  line  of  life,  ex- 
empted from  it :  it  happens  equally  to  the  opulent 
and  to  the  moft  indigent ;  and  I  have  met  with  it  in 
all  ages,  from  the  fixteenth  to  the  feventieth  and 
eightieth  year,  but  not  fo  frequently  in  early  youth, 
as  in  more  advanced  ftages  of  life.  In  a  great  pro- 
portion of  ca'es,  the  difeafe  begins  in  the  body  of  the 
teftis,  afie<^ing  the  whole  of  it  equally  ;  but  in  fome, 
it  makes  its  firft  appearance  in  the  epididymis,  and 
occafionally  even  in  the  fpermatic  cord.  It  has  been 
a  prevailing  opinion,  indeed,  that  a  fchirrous  hard, 
nefs,  tending  to  cancer,  never  begins  in  the  epididy- 
mis, and  that  the  tefticle  is  always  firft  affedled. 

This  is  certainly  in  general  the  cafe,  but  every  prac- 
titioner muft  at  times  have  met  with  inftances  of  can- 
cer beginning  in  the  epididymis,  and  fometimes  even 
in  the  fpermatic  cord,  and  fpreading  from  thence  to 
the  neighbouring  parts.  I  might  here  infert  different 
cales  which  have  fallen  within  my  own  obfervation  ; 
but  Mr.  Pott's  collection  furniflies  a  fufficient  number 
of  well  marked  examples.* 

*  Treatifc  on  the  Hydrocele,  cafes  4»,  48,  and  491 


122  Of  the  Sarcocsk.         Chap.  XX VIL 

In  almofl;  every  cafe  of  fwelled  tefUcle  from  gonor- 
rhoea, the  epididymis  is  not  only  affeded  before  the 
teflicle,  by  the  inflammation  fpreading  from  the  ure- 
thra, along  the  vas  deferens ;  but  the  fwelling,  when 
it  begins  to  yield,  always  firft  removes  from  the  tefli- 
cle, leaving  in  general,  a  hardened  ftate  of  the  epidi- 
dymis, which  for  the  mod  part,  continues  in  fome 
degree  during  life.  But  as  the  hardnefs  produced  in 
this  manner  is  entirely  the  effeft  of  infianmiation  up- 
on a  membranous  or  vafcular  part,  fo  here,  as  in  oth- 
er parts  of  the  body,  of  a  fimilar  texture,  we  feldom 
find  that  hardnefs  induced  by  inflammation  terminates 
in  cancel*. 

The  contrary  however,  of  this  has  been  inculcated  ; 
and  it  has  even  been  faid,  that  the  hernia  humoralis 
produced  by  gonorrhoea,  and  that  tumor  of  the  teftis 
which  we  fometimes  meet  with  from  lues  venerea,  are 
frequent  caufes  of  farcocele  ;  which  in  various  inftan- 
ces  has  done  harm,  by  tending  to  prevent  a  trial  of 
mercury,  the  only  remedy  which  in  tumors  of  the 
teftis  arifmg  from  this  caufe,  has  ever  as  yet  proved 
of  any  real  utility. 

But,  although  tumors  of  the  teflis,  from  a  venereal 
caufe,  feldom  terminate  in  this  manner,  yet  I  will  not 
go  fo  far  as  to  fay  that  they  never  have  done  fo  ;  for 
I  know,  that  a  hardened  flate  of  the  teflis  and  epidi- 
dymis produced  originally  from  a  venereal  taint,  does 
in  fome  inflances,  degenerate  into  the  worfl  fpecies  of 
farcocele.  That  is,  that  although  tumors  in  this  part, 
arifmg  from  lues  venerea,  are  mofl  frequently  cured 
by  mercury,  yet  occafionally  and  in  particular  confli- 
tutions,  the  peculiarities  of  which,  however,  we  are 
not  acquainted  with,  they  do  certainly  end  in  fchirrus 
of  the  worfl  kind,  a  difeafe  which  might  never  proba- 
bly have  appeared,  if  the  original  venereal  taint  had 
not  afted  as  an  exciting  caufe  of  it.  We  know  that 
a  predifpolition  to  difeafes  will  remain  long  in  a  latent 
(late  in  the  fyflem,  without  any  evident  fymptom  be,- 
ing  excited,  till  the  application  of  fome   particular  , 


Chap.  XXVII.         Of  the  Sarcocek.  12^ 

ftimulus  brings  it  into  a£tion.  In  the  fame  manner, 
a  venereal  affection  of  the  teftis,  or  even  that  hardnefs 
of  the  epididymis  that  remains  after  an  inflammatory- 
tumor  of  thele  parts  from  gonorrhoea,  will  in  fome 
confliitutions,  terminate  in  farcocele,  akhough  in  a 
great  proportion  of  cafes  it  is  otherwife,  and  no  dif- 
treisful  confequence  refults  from  them. 

I  have  dwelt  the  longer  upon  this,  from  a  contrary 
dodrinc  having  been  ilrenuoufly  inculcated  by  one 
whofe  authority  is  defervedly  great,  and  whofe  obfer- 
vation  in  this  cli'eafe  has  led  to  the  conclufion  he  en- 
deavours to  ellabiifli.*  But,  as  the  refult  of  my  ex- 
perience has  been  eAa6tly  what  I  have  flated,  I  could 
not  avoid  fpeaking  of  it  in  the  manner  I  have  done. 

In  the  treati'e  to  which  I  allude,  we  are  told,  that 
hernia  humoralis  is  never  productive  of  farcocele.  If, 
on  this  fubje6l,  Mr.  Pott's  idea  is  juft,  it  ought  un- 
doubtedly to  be  received  ;  but,  if  it  is  not,  it  may  cer- 
tainly do  harm,  by  rendering  both  patients  and  practi- 
tioners more  remiis  in  cafes  of  farcocele  proceeding  from 
this  cau^e,  than  they  otherwife  would  be  ;  as,  by  con- 
tinuing ftill  to  expect  that  a  mercurial  courfe  may  ac- 
complifli  a  cure,  they  may  allow  the  difeafe  to  go  too 
far  before  extirpation  is  advifcd. 

In  every  doubtful  cafe,  when  lues  venerea  is  fufpe£l:- 
ed  to  be  the  caufe  of  the  tumor,  bloodletting,  when 
the  pulfe  is  full,  an  open  belly,  a  cooling  diet,  a  hori- 
zontal pofture,  a  proper  fufpenfory  bandage,  and  a 
well  directed  courfe  of  mercury,  will  commonly  re- 
move it.  But,  when  thefe  means  are  employed  with- 
out advantage  ;  and  efpecially  if,  during  their  applica- 
tion, the  tumor,  inflead  of  decreafmg,  becomes  grad- 
ually worfe,  as  foon  as,  from  its  increafe,  there  appears 
to  be  any  rifk  of  its  advancing  too  far  to  admit  of  be- 
ing extirpated,  it  ought,  without  further  hefitation,  to 
be  removed,  whatever  the  caufe  may  be  by  which  it 
was  at  firft  produced. 

•  Mr.  Pott,  Treatife  on  the  Hydrocele,  Sec.  p.  331. 


1 24  Of  the  Sarcccck,         Chap.  XXVII. 

.  Among  other  caufes  which  authors  have  mentioned 
of  farcocele,  is  the  hydrocele  of  the  tunica  vaginalis. 
From  quantities  of  a  fcrous  fluid  being  frequently  found 
in  the  vaginal  coat  of  a  fchirrous  teflicle,  it  has  been 
fuppofed,  that  the  water,  in  fuch  cafes, 'was  the  origi- 
nal caufe,  and  not  the  eifeO:  of  the  difeafe  in  the  tef- 
tis.  There  is  much  reafon,  however,  to  think,  that 
in  thefe  coUcclions  of  water  in  the  tunica  vaginalis,  in 
which  the  tcftis  is  found  difeafed,  that  the  hardened 
ftate  of  that  organ  ought  to  be  confidered  as  the  orig- 
inal difeafe,  and  not  the  water  which  furrounds  it. 

Colleftions  of  water  are,  no  doubt,  often  met  with, 
even  in  a  real  farcocele  ;  but  this  we  are  to  confider 
entirely  as  a  diflerent  ftage  of  the  fame  difeafe  :  for, 
although  the  true  farcocele  is  not  at  firft  attended  with 
any  colleclion,  either  of  blood  or  ftrum,  it  is  natural 
to  fuppofe,  that  an  enlarged  or  hardened  ftate  of  the 
teftis  muft  have  feme  influence,  both  on  the  quantity 
and  appearance  of  the  fluid  with  which  the  tunica  va- 
ginalis is  always  provided. 

If  it  either  excites  an  augmented  fecretion,  or  a  di- 
minifhed  abforption  of  this  fluid,  a  dropfical  fwelling 
muft  take  place  ;  and  every  fuch  collection  combined 
with  a  fchirrous  tefticle,  has  been  very  properly  term- 
ed a  hydro-farcocele. 

That  the  teftis,  by  remaining  long  immerfed  in  the 
ferum  even  of  a  true  hydrocele,  is  frequently  altered 
in  its  texture,  there  is  no  reafon  to  doubt.  Thus,  on 
laying  open  the  tunica  vaginalis  in  a  common  hydro- 
cele, the  teftis  is  very  commonly  of  a  more  pale  ap- 
pearance than  in  a  ftate  of  health. 

In  feme  cafes,  it  is  much  diminiflicd,  and,  in  others, 
confiderably  enlarged  ;  but  all  fuch  enlargements, 
when  connected  v/ith  a  real  hydrocele,  are  of  a  foft, 
harmlefs  nature,  and  never  give  pain.  In  this  ftate, 
the  teftis  Ihould  never  be  extirpated. 

This  is  a  point,  I  may  remark,  which  it  is  of  much 
importance  to  afcertain  :  for,  on  the  idea  of  this  en- 
largement of  the  teftis,  frequently  connected  with,  aod 


Chap.  XXVir.         Of  the  Sarcoccle.  125 

perhaps  produced  by  immerfion  in  the  water  of  a  hy- 
drocele, being  truly  fchirrous,  the  operation  of  caftra- 
tion  has  been  often  advifed,  and  unfortunately  pradif- 
ed.  In  circumflances  of  doubt,  the  means  of  diftinc- 
tion  between  the  mild  and  malignant  variety  of  en- 
larged tefticle,  by*  which  we  fhould  in  general  be  di- 
rected, are  thefc  :  when  either  the  body  of  the  teflis 
or  epididymis,  or  both,  are  hard  and  enlarged  previ- 
ous to  any  collection  of  fcrum  in  the  tunica  vaginalis, 
fuch  collections  as  afterwards  take  place  ought  not  to 
be  confidcred  as  conftituting  a  fimple  hydrocele.  If 
the  tumor  has  been  accompanied  with  pain,  and  if, 
upon  difcharging  the  ferum  by  inciuon,  the  teftis,  be- 
lides  being  enlarged,  is  hard  or  ulcerated -on  its  fur- 
face,  extirpation  fhould  be  immediately  advifed  ;  but, 
on  the  contrary,  when  the  water  of  a  hydrocele  is 
known  to  have  been  collected  while  the  tefticle  re- 
mained found,  and  of  its  natural  fize,  whatever  en- 
largement it  may  be  found  to  have  acquired  on  laying 
the  fac  open,  if  the  teftis  is  neither  of  a  fchirrous  hard* 
nefs,  nor  aft'edted  v^ith  pain  or  ulceration,  we  ought 
unqueftionably  to  proceed  as  in  a  cafe  of  fimple  hy- 
drocele ;  for,  this  kind  of  enlargement  will  be  rarely 
found  to  excite  future  uneafmefs,  and  will  confequent- 
ly  feldom  or  never  render  extirpation  neceifary. 

In  judging  of  the  probable  termination  of  a  fchir- 
rous tefticle,  different  circumftances  require  attention  : 
the  a,ge  and  habit  of  body  of  the  patient,  the  duration 
of  the  difeafe,  and  the  ftate  it  is  in  at  the  time. 

Thus,  whatever  treatment  is  to  be  adopted,  more 
fuccefs  may  be  reafonably  expected  in  a  young  heal- 
thy perfon,  than  in  the  reverfe  ;  particularly  if  extir- 
pation of  the  teftis  is  to  be  advifed.  In  patients  that 
are  otherwife  in  good  health,  the  chance  of  fuccefs 
from  the  operation  is  commonly  confiderable,  provi- 
ded the  difeafe  is  not  too  far  advanced  ;  whereas,  in 
old  or  infirm  people,  and  in  habits  attended  with  pale, 
wan  complexions,  with  indigeftion,  and  other  fymp. 


1 26  Of  the  Sarcccek.         Chap.  XXVII. 

toms  of  obftrucled  vifcera,  whatever  flate  the  difeafe 
may  be  in,  Httle  or  no  advantage  is  Ukely  to  accrue 
from  any  operation. 

The  complexion,  of  itfelf,  I  muft  obferve,  does  not, 
in  this  difeafe,  merit  much  attent:on  ;  for,  I  have 
fcarcely  met  v/ith  an  inflance  of  th€  true  farcocele,  ev- 
en in  the  early  and  mofl  fimple  (lage  of  the  difeafe,  in 
which  a  pale  complexion  did  not  take  place.  It  feems 
to  be,  in  a  great  meafure,  the  effect  of  that  anxiety 
and  dread  for  the  final  event  of  the  difeafe,  to  which 
patients,  with  tumors  of  this  defcription,  are  particu- 
larly liable ;  but  it  is  materially  different  from  that 
wan,  fickly  countenance,  often  accompanied  with  a 
flight  tinge 'of  bile,  that  we  meet  with  in  the  advanced 
ftate  of  the  difeafe,  when  attended  with  obftructions 
of  any  of  the  abdominal  vifcera. 

With  refpecl  to  the  duration  of  the  difeafe,  if  it  has 
already  fubfifted  for  a  confiderable  time  without  mak- 
ing progrefs,  there  will  be  reafon  to  think  that  it  is  of 
a  mild  nature,  and  that  the  fyftem  is  not  fo  much  af- 
fefted  as  if  its  progrefs  had  been  great  and  rapid  ;  and, 
laftly,  the  flate  of  the  tumor  at  the  time  is  of  much 
importance  in  forming  a  prognofis  of  the  event.  As 
long  as  the  teftlcle  is  only  fomewhat  hard  and  enlarg- 
ed, without  the  formation  of  matter,  and  without  any 
difeafe  of  the  cord,  if  the  conftitution  is  otherwife 
healthy,  there  will  be  much  caufe  to  hope  for  a  fa- 
vourable event  from  any  operation  that  is  advifed. 

But,  on  the  contrary,  when  the  difeafe  is  fo  far  ad- 
vanced, that  colledions  of  matter  have  formed,  either 
upon  the  furface  of  the  tefticle,  or  in  its  more  inter- 
nal parts,  as  in  this  flate  there  will  be  caufe  to  fufpedl 
that  the  conflitution  has  fuft'ered  from  abforption,  fo 
there  will  be  lefs  caufe  to  hope  that  the  operation  will 
prove  fuccefsful,  than  in  the  more  early  flages  of  the 
difeafe.  And  this  is  more  remarkablv  the  cafe,  when 
ulcerations  have  taken  place  on  the  furface  of  the  tu- 
mor ;  for  we  know  well  that  abforption  is  much 
more  apt  to  occur  from  tumors  in  a  flate  of  ulcera- 


Chap.  XXVII.         Of  the  Sarco£eIe,  1 27 

tion,  than  from  matter  to  which  the  air  does  not  get 
accels. 

In  whatever  ftate,  however,  the  tumor  may  be,  there 
is  always  reafon  to  hope  for  more  fuccefs  from  the 
operation  while  the  fpermatic  cord  is  yet  found,  than 
when  it  has  become  difeafed  ;  for,  as  loon  as  the  cord 
is  much  affected,  the  chance  of  fuccefs  from  any 
means  that  can  be  attempted,  will  be  proportionally 
lefs.  The  cord,  indeed,  may,  towards  its  under  ex- 
tremlt)'-,  be  difeafed,  even  in  the  fame  manner  with 
the  teliis  itfclf,  without  leflening  the  chance  of  benefit 
from  the  operation;  but,  whenever  the  difeafe  has 
fpread  fo  far  up  the  cord  as  to  render  it  doubtful 
whether  the  parts  affeded  can  be  all  removed  by  the 
knife  or  not ;  and  efpecially,  if  there  is  reafon  to  think 
that  the  cord  is  difeafed  within  the  boundaries  of  the 
abdomen,  inflead  of  there  being,  in  fuch  circumftan- 
ces,  any  advantage  to  be  expected  from  the  operation, 
every  attempt  towards  the  removal  of  the  parts  below^ 
will,  for  certain,  tend  to  aggravate  the  fymptoms,  and 
haften  the  death  of  the  patient. 

When  a  fchirrous  or  cancerous  tumor  is  fo  fitu- 
atcd,  that  it  can  be  entirely  removed,  the  operation 
ought  immediately  to  be  advifed  ;  but  when  the  dif- 
eafe has  advanced  fo  far  as  to  render  this  impofliblc, 
in  whatever  part  of  the  body  it  may  be  feated,  no  at- 
tempt of  this  kind  fhould  be  made,  the  fact  being  now 
clearly  afcertained,  that  canerous  atlections  are  always 
rendered  worfe  by  extirpation,  when  all  the  difeafed 
parts  cannot  be  removed. 

It  is  of  much  importance,  however,  to  obferve,  that 
the  fpermatic  cord  freqently  becomes  full  and  thick, 
merely  by  the  weight  of  the  tumor,  without  being  in 
any  other  refpeft  difeafed.  A  fulnefs  of  this  kind, 
when  the  cord  itfelf  is  not  painful,  and  when  no  knots 
or  inequalities  have  formed  upon  its  furface,  ought 
not  to  prevent  the  operation,  when  in  other  rcfoedls, 
it  appears  to  be  neceffary  ;  for,  a  mere  enlargement 
of  the  cord  very  frequently  occurs,  either  from  a  vari- 


123  Of  the  Sarccccle.         Chap.  XXVII. 

cofe  date  of  the  velTcls,  or  from  a  watery  depofition 
in  the  cellular  fubflance  of  the  part,  when  it  is  not  in 
any  other  manner  difeafed.*  But,  when  the  cord,  at 
the  fame  time  that  it  has  become  enlarged,  hard,  and 
knotty,  adheres  to  the  neighbouring  parts,  is  painful 
to  the  touch,  or  ulcerated,  thefe,  if  the  difeafe  extends 
over  the  whole  procefs,  up  to  the  abdominal  mufcles, 
are  circumftances  which,  with  every  prudent  pradti- 
tioner,  will  at  all  times  forbid  the  operation  of  cailra- 
tion. 

It  has  indeed,  been  propofed,  in  this  flate  of  the 
cord,  to  enlarge  the  opening  in  the  external  oblique 
mufcle,  fo  as  by  diil'edion,  to  trace  the  difeafed  parts 
even  into  the  cavity  of  the  abdomen,  with  a  view  to 
remove  them  entirely.  But,  although  theoretical  wri- 
ters may  attempt  to  amufe  their  readers  with  fuch  pro- 
pofals,  they  will  never  be  feriouily  thought  of  by  prac- 
titioners whofe  opportunities  for  obfervation  enable 
them  to  think  and  aft  for  themfelves. 

It  is  unnecelTary  here  to  enumerate  either  internal 
medicines  or  external  applications,  as  none  have  been 
employed  with  advantage  for  the  removal  of  this  dif- 
eafe. Cicuta  and  belladona,  fo  much  celebrated  in 
cancer,  have  no  effect  in  arrefting  its  progrefs,  or  in 
mitigating  its  fymptoms.  It  is  on  the  extirpation  of 
the  difealed  parts  that  we  alone  rely  for  a  cure  :  hence, 
it  is  a  point  of  the  firfi:  importance,  to  afcertain  the  pe- 
riod of  the  difeafe  at  which  the  operation  fliould  be 
propofed. 

I  have  already  obferved,  that  occafionally  we  meet 
•Avith  a  fchirrous  enlargement  of  the  teflis,  with  which 
♦  patients  walk  about  for  a  great  length  of  time,  with 
little  or  no  inconvenience.  Such  inflances,  however, 
are  rare ;  for  by  much  the  greatell  proportion  prove 
to  be  of  a  malignant  nature,  and  proceed  rapidly  to  a 
flate  of  pain  and  hazard.     I  may  therefore  obferve, 

*  Of  the  point  here  inculcated,  fome  Cn^lar  proofs  are  recorded  by 
Mr  Pott,  in  his  ulcful  coUcclion  of  cafes.  Sec  TrcatiJc  on  the  Kydrocele, 
Cafes  xxi:ix.  xl.  xlix.  and  l. 


Chap.  XXVII.         Of  the  Sarcoceie.  129 

that,  whenever  a  fchirrous  or  hardened  ftate  of  the 
tefticle  does  not  yield  to  the  means  ufually  advifed  for 
it,  fuch  as  moderate  evacuations  of  blood,  when  thefe 
are  indicated,  a  cooling  diet,  a  lax  belly,  the  ufe  of  a 
fufpenlory  bandage,  and  efpccially  when  mercury, 
which,  on  the  chance  of  the  difeafe  being  venereal,  is 
very  commonly  tried,  are  all  ufed  without  advantage, 
v/c  may,  in  fuch  circumftanccs,  always  have  much 
caufe  to  fufpeft  that  the  difeafe  is  of  the  word  kind. 
When  more  inveterate  fymptoms  appear,  when  the 
tumor,  which,  till  now,  was  in  a  hard  indolent  ftate, 
becomes  painful,  and  increafes  in  bulk,  no  further  de- 
lay (hould  be  advifed.  For,  however  improper  it 
would  be  to  remove  a  hardened  teftis,  which,  for  a 
confiderable  time,  had  remained  indolent,  without 
pain  or  increafe,  it  would  be  equally  unpardonable  in 
any  praditioner  to  advife  the  operation  to  be  delayed, 
when  matters  are  fo  far  changed,  that  the  tumor  is 
attended  with  much  pain,  and  daily  becoming  larger. 
In  fuch  circumflances,  the  fooner  the  difeafed  parts 
are  removed,  the  greater  will  be  the  chance  of  a  re- 
covery ;  fo  that  not  a  day'  fliould  be  loft  :  for,  what- 
ever the  opinion  of  the  late  Mr.  Sharpe  on  this  point 
may  have  been,  as  well  as  of  fome  others  who  appear 
to  have  copied  from  him,  it  has  long  been  a  fixed 
maxim  with  the  moft  experienced  furgeons,  that,  in 
all  cafes  of  cancer,  the  rifk  of  a  relapfe  after  the  ope- 
ration, is  commonly  in  proportion  to  the  duration  of 
the  difeafe.* 

The  extirpation  of  the  tefticle  being  refolved  on, 
the  method  of  doing  it  is  this  :  the  patient  muft  be 
laid  on  a  table  of  a  convenient  height,  with  his  legs 
hanging  down,  and  firmly  fecured  by  two  afTiftants  on 

•  The  opinion  of  the  late  Mr,  Sharpe,  on  this  point,  was  fingular  in  a 
Bian  of  fuch  extcnfive  experience.  He  confidered  the  rifle  of  a  rclapfc,  af- 
ter the  extirpation  of  cancerous  tumors,  to  be  greater  in  the  more  early 
periods  of  the  difeafe,  than  in  their  more  advanced  ftates.  Critical  Inqui* 
ry,  4th  edit.  p.  108. 

Vol.  III.  K 


130  Of  the  Sarcoccle,        Chap.  XXVIl. 

each  fide ;  one  at  each  arm,  and  another  fupporting 
each  leg.  The  parts  being  pre\'ioufly  Ihaved,  if  tha 
tumor  is  large,  an  afliftant  mud  be  employed  to  fecure 
it ;  if  only,  however,  of  a  moderate  fize,  the  furgeon 
will  do  it  beft  himfelf.  With  one  hand,  therefore,  he 
Jhould  grafp  the  fwelling,  fo  as  to  keep  it  firm,  and 
with  a  fcalpel  in  the  other,  an  incifion  fhould  be  made 
along  the  whole  courfe  of  it,  beginning  at  leaft  an  inch 
above  the  part  where  the  cord  is  to  be  cut,  and  con- 
tinuing it  through  the  Ikin  and  cellular  fubflance,  to 
the  inferior  part  of  the  fcrotum.  The  eafieft  method 
of  doing  it,  both  for  the  furgeon  and  patient,  is  by 
one  continued  ftroke  of  the  knife,  as  it  is  both  more 
quickly  and  more  neatly  performed  in  this  manner, 
than  in  the  ufual  way  of  pinching  up  the  ikin  between 
the  finger  and  thumb,  before  cutting  it ;  and  there  is 
no  kind  of  difficulty  or  rifk  in  doing  it  in  this  manner. 

The  fpermatic  cord  being  thus  laid  bare,  the  fur- 
geon, with  the  finger  and  thumb  of  one  hand,  fhould 
raife  it  from  the  parts  beneath,  fo  as  to  be  enabled  to 
pafs  a  broad  waxed  ligature  round  it ;  which  is  eafily 
done  with  a  large  curved  needle,  or  even  with  a  blunt 
probe,  with  an  eye  at  one  end.  With  this  ligature,  a 
running  knot  fhould  be  made  upon  the  cord,  about 
half  an  inch  above  where  it  is  to  be  divided. 

The  cord  being  at  this  part  cut  acrofs  with  the  fcal- 
pel, the  tefticle  is  then  to  be  entirely  removed,  by  dif- 
fering the  cord  and  it  from  above  downwards,  fo  as 
to  feparate  them  as  eafily  as  pofTible  from  the  furround- 
ing  parts,  without  injuring  the  found  Ikin  with  which 
they  were  covered.  Different  inftruments  have  been 
propofed  for  facilitating  the  feparation  of  the  teflis  from 
the  contiguous  parts  ;  but  none  with  which  we  are 
acquainted  anfwers  the  purpofe  fo  well,  or  with  fuch 
expedition  as  a  fcalpel. 

When  the  difeafed  parts  are  removed,  any  arteries 
of  the  fcrotum  that  have  been  divided,  fhould  be  firfl 
fecured  with  ligatures,  by  means  of  the  tenaculum. 
This  being  done,  the  fpermatic  artery  and  vein  fhould 


Chap.  XXVII.        Of  the  SarcQcele.  131 

be  gently  feparated  from  the  nerve  with  which  they 
are  in  contact,  and,  by  the  aid  of  a  tenaculum,  (hould 
be  tied  with  a  fmall  Hgature  of  waxed  filk.  By  in- 
cluding the  nerve  in  the  ligature,  as  is  commonly 
done,  we  render  this  the  moft  painful  part  of  the  op- 
eration, whila  no  advantage  whatever  is  gained  by  it. 

The  ligature  previoufly  pafTed  round  the  cord,  (hould 
be  untied  ;  but  it  fhould  not  be  withdrawn.  Leil  the 
ligatures  of  the  fpermatic  artery  and  vein  fliould  give 
way,  this  ligature  (liould  be  allowed  to  remain  during 
the  firll  eight  or  ten  days  of  the  cure,  and,  being  per- 
fedly  loofe,  no  harm  can  be  done  by  it.  It  is  meant 
merely  as  an  additional  fecurity,  and  to  ferve  as  a  kind 
of  tourniquet,  in  the  event  of  any  hemorrhage  taking 
place  ;  fo  that,  in  circumftances  fuch  as  we  are  now 
confidering,  it  ought  always  to  be  left  loofe.  There 
is,  in  fadl,  no  more  necellity  for  allowing  this  ligature 
to  remain  tied,  than  for  leaving  a  tourniquet  firmly 
applied  upon  any  of  the  extremities  after  the  operation 
of  amputation  ;  and  yet,  inftead  of  one  ligature,  fuch 
as  this,  it  has  been  the  practice  with  many  to  apply 
two,  about  half  an  inch  diilant  from  each  other ;  and 
thefe  they  leave  firmly  tied  upon  the  whole  fubftance 
of  the  cord  during  the  cure  of  the  fore.* 

There  is,  however,  no  necelTity  for  this  precaution, 
as  all  manner  of  rifk  may  be  prevented,  by  fecuring 
the  blood  veflels  in  the  manner  I  have  pointed  out. 
I  have  often  done  the  operation  in  this  way,  and  no 
hazard  has  ever  enfued  from  it.  By  leaving  the  liga- 
ture at  the  upper  part  of  the  wound  untied,  it  may  be 
made  ufe  of,  as  I  have  already  obferved,  to  comprefs 
the  cord,  in  the  event  of  the  blood  vefTels  burfting  out 
again ;  but,  when  the  ligature  upon  the  fpermatic  ar- 
tery and  vein  is  properly  applied,  this  will  never  hap- 
pen ;  and  when  it  occurs  from  negled:  or  mifmanage- 
ment,  any  fevere  hemorrhage  may  always  be  prevent- 
ed by  the  ligature  left  for  that  purpofe. 

•  Even  the  late  Mr.  Sharpe  gives  thefe  direiStions.  Vide  Trcatife  on 
the  Operations  of  Surgery,  loth  edit.  p.  j  j. 

K   2 


132  Of  the  Sarcocele,         Chap.  XXVII. 

On  the  arteries  being  tied,  the  edges  of  the  cut 
fhould  be  laid  together,  and  fecured  with  adhefive 
plafter,  when  the  retraclion  is  inconfiderable  ;  and, 
with  the  interrupted  future,  when  it  appears  from  the 
retradion  that  takes  place  to  be  neceilary.  At  the 
fame  time,  care  fliould  be  taken  to  Icatte  the  ends  of 
the  Hgatures  employed  for  fecuring  the  blood  veffels, 
hanging  out  at  the  edges  of  the  wound,  to  admit  of 
their  being  withdrawn,  when,  in  the  courfc  of  the  cure, 
they  appear  to  have  become  loofe.  The  whole  fcro- 
tum  (hould  be  covered  with  a  pledget  of  foft  linen, 
fpread  with  faturnine  cerate  ;  and  a  culhion  of  tow, 
covered  with  old  linen,  being  laid  over  it,  the  whole 
fhould  be  fecured  with  a  fufpenfory  bag,  or  the  T 
bandage. 

At  the  end  of  the  fecond  or  third  day,  the  dreflings 
fhould  be  removed :  it  is  eafily  done,  when  the  parts 
are  covered  in  the  manner  I  ha\e  advifed,  with  cerate  ; 
and  it  always  keeps  the  patient  more  comfortable  than 
when  the  firfl;  dreffing  is  long  delayed.  For  the  fame 
reafon,  the  dreflings  fhould  be  renewed  daily.  In  the 
courfe  of  eight  or  ten  days,  the  ligatures  commonly 
feparate,  and  are  eafily  taken  away.  About  the  fame 
period,  the  ligature  pafled  beneath  the  fpermatic  cord 
may  be  withdrawn ;  and  by  the  fourteenth  or  fifteenth 
day,  the  cure,  when  conduced  in  this  manner,  is  for 
the  mofl  part  complete. 

Hitherto  we  have  been  fuppofmg  that  the  tegu- 
ments covering  the  tefhicle  are  found,  in  which  cafe 
none  of  them  fhould  ever  be  taken  away  ;  but,  when 
the  fkin  has  become  thin  and  inflamed,  and  efpecially 
when  any  of  it  is  in  a  ftate  of  ulceration,  all  fuch  parts 
of  it  fhould  be  removed  along  with  the  tefticle.  In 
fuch  circumfl:ances,  the  beft  method  of  doing  the  op- 
eration is  this :  inftead  of  a  longitudinal  cut  along  the 
courfe  of  the  teiliclc,  the  firfl  incifion  fhould  be  car- 
ried in  a  flraight  line  to  the  under  extremity  of  the 
fpermatic  cord,  from  whence  two  femilunar  incifions 
fhould  be  continued  to  the  under  part  of  the  fcrotum, 


Chap.  XXVII.         Of  the  Sarcocek,  133 

and  in  their  courfe,  be  made  to  mclude  all  difeafed 
parts  of  the  fkin. 

The  remainder  of  the  operation  fhould  be  finifhed 
in  the  manner  that  I  have  defcribcd,  and  the  (kin  in- 
cluded in  the  two  femilunar  cuts  not  be  difledted  off 
by  itfelf,  but  removed  along  with  the  teflicle. 

Even  where  a  large  portion  of  the  teguments  have 
been  removd,  the  fore  may  be  covered  with  fkin  ;  nor 
fhould  this  ever  be  omitted,  when  we  find  it  can  be 
done  ;  for  it  not  only  haftens  the  cure,  but  ferves  as 
a  more  firm  protedion  to  the  end  of  the  fpermatic 
procefsj  feptum  fcroti,  and  contigQous  parts,  than  the 
new  fcarf  ikin,  with  which  alone  they  would  other- 
wife  be  covered.  But  when  the  remaining  teguments 
will  not  flretch  fo  much  as  to  admit  of  their  being 
retained  either  with  plafters  or  futures,  the  cure  mufl 
neceflariiy  be  conduced  in  the  ufual  way,  by  drefling 
with  pledgets  of  any  emollient  ointment,  till  a  cica- 
trix is  induced.  The  advantages  however,  that  we 
derive  from  being  able  to  cover  the  fore  entirely  with 
fkin,  are  fo  great,  that  every  operator  fliould  keep  it 
anxioufly  in  view ;  for,  befides  thofe  I  have  mention- 
ed, it  faves  a  great  deal  of  pain  and  confinement,  to 
which  the  patient  muft  otherwife  fubmit.  It  admits, 
indeed,  of  a  cure  in  the  fourth  part  of  the  time  com- 
monly required  when  the  edges  of  the  fkin  cannot  be 
kept  together. 

From  the  defcrlptions  ufually  given  of  caflration, 
we  would  be  induced  to  confider  it  as  one  of  the  moft 
fmiple,  as  well  as  the  moft  eafy  in  furgery ;  and  it 
muft  be  admitted,  that  in  the  early  ftages  of  a  farco- 
cele,  fcarcely  any  difficulty  ever  attends  it.  But  it  is 
right  that  the  younger  part  of  the  profcffion  fhould  be 
informed  of  what  all  practitioners  of  experience  know, 
that  fcarcely  any  operation  is  productive  of  more  per- 
plexing occurrences  in  the  advanced  periods  of  the 
difeafe. 

When  the  fpermatic  cord  is  fo  much  difeafed,  that 
"we  are  obliged  to  divide  it  near  the  abdominal  muf- 


134  Of  the  Sarcocele.         Chap.  XXVII. 

cles,  if  the  upper  part  of  it  is  not  previoully  fecured 
with  a  ligature,  it  is  apt  to  retract  within  the  abdo- 
men, fo  as  to  render  it  impoflible  to  fecure  it  in  any 
other  manner  than  by  dividing  the  abdominal  muf- 
cles.  Of  this  I  have  now  been  prefent  at  two  inftan- 
ces,  in  both  of  which  the  cord  retracted  fuddenly  with 
a  fniart  jerk,  inflantly  on  being  divided. 

In  one  of  thefe  cafes,  no  ligature  had  been  applied, 
as  the  afliftant  imagined  that  he  could  fecure  the  cord 
between  his  finger  and  thumb  till  the  fpermatic  artery 
could  be  tied,  but  in  which  he  was  miftaken  ;  and  in 
the  other,  the  ligature  not  being  tied  fufficiently  tight, 
it  flipped  off  from  the  end  of  the  cord ;  and  in  both 
inftances,  the  patients  died  of  the  hemorrhage.  Ex- 
ternal preflure  was  the  only  remedy  that  could  be  em- 
ployed ;  but  although  in  both  inftances  it  gave,  from 
time  to  time,  a  temporary  check  to  the  difcharge,  it 
did  not,  in  either  cafe,  prove  effedlual ;  fo  that  after 
various  returns  of  the  hemorrhage,  the  patients  were 
at  laft  carried  oft'  by  inanition. 

In  all  cafes,  therefore,  where  the  cord  muft  be  cut 
in  the  upper  part  of  it,  a  ftrong  ligature  ftiould  be 
previoully  firmly  tied,  as  far  as  poffible  above  the  part 
in  which  the  divifion  is  to  take  place.  It  fhould  be 
applied  with  a  running  knot,  and  left  of  fuch  a  length 
as  to  admit  of  the  ends  of  it  hanging  freely  out  of  the 
wound.  Being  made  with  a  running  knot,  it  may  be 
eafily  undone,  whenever  it  may  be  fuppofed  that  no 
hemorrhage  will  occur  on  its  being  withdrawn ;  and 
if  the  end  of  the  ligature  is  twice  paffed  through  the 
firft  noofe,  it  will  be  fufftciently  firm. 

The  pain  attending  this  mode  of  applying  the  liga- 
ture, is,  no  doubt,  much  more  fevere  than  when  the 
nerve  is  avoided  ;  but  in  the  fituation  to  which  I  al- 
lude, where  the  cord  is  cut  near  to  the  abdominal 
mufcles,  this  cannot  with  fafety  be  done,  and  ftiould 
not  therefore  be  attempted. 

In  confiderable  enlargements  of  the  teftis,  the  tu- 
mor is  apt  to  prefs  fo  much  upon  the  feptum  fcroti, 


Chap.  XXVII.        Of  the  Sarcocek.  135 

and  in  fome  Inftances,  adheres  to  it  fo  firmly,  that  the 
cavity  of  the  tunica  vaginalis  of  the  oppofite  fide  is 
fometimes  opened  in  the  courfe  of  the  operation.  Of 
this  I  have  been  prefent  at  difi'erent  inftances :  in  fome 
no  inconvenience  enfued  from  it ;  but  in  others,  In- 
flammation to  an  extenfive  degree,  was  induced  in  the 
correfponding  tefticle.  With  fufficient  caution,  how- 
ever, in  the  removal  of  the  tumor,  all  this  may  be 
prevented ;  for,  however  large  it  may  be,  the  dilTec- 
tion  may  be  always  accompUfhed  without  perforating 
the  feptum.  When  it  is  perceived,  however,  that  an 
opening  is  by  accident  made  in  it,  in  order  to  prevent 
that  inflammation  of  the  teftis  which  free  accefs  of  air 
very  feldom  fails  to  induce,  I  would  advife  the  divid- 
ed parts  to  be  neatly  and  gently  drawn  together  with 
a  ligature,  in  fuch  a  manner  as  to  admit  of  its  being 
eafily  withdrawn  in  the  courfe  of  the  cure.  By  this, 
we  alfo  prevent  blood  and  matter  from  finding  accefs 
to  the  tunica  vaginalis. 

But  the  moft  diftrefsful  part  of  this  operation  arifes 
from  that  enlarged  ftate  of  the  arteries  of  the  fcrotum, 
which  takes  place  in  every  inftance  where  the  tumor 
has  acquired  a  great  bulk,  and  from  which  practition- 
ers occafionally  meet  with  more  embarraflfment  than 
is  ufually  experienced  in  any  other  operation.  Inftead 
of  one,  two,  or  three  arteries,  very  inconfiderable  in 
fize,  which  in  the  firft  ftages  of  the  difeafe,  are  all  that 
we  perceive  ;  in  the  more  advanced  ftates  of  it,  we 
fometimes  meet  with  fix,  eight,  or  even  more,  and  all 
or  many  of  them,  of  fuch  a  fize  as  to  require  imme- 
diate attention. 

In  this  period  of  the  difeafe,  the  patient  is  com- 
monly weak  and  delicate  ;  fo  that  not  being  able  to 
bear  the  lofs  of  much  blood,  his  ftrength  would  fink, 
if  arteries  of  the  fize  which  thefe  often  acquire  were 
allowed  to  bleed  during  the  remainder  of  the  opera- 
tion. During  the  removal  of  the  tumor,  one  or  more 
afTiftants  fhould  be  employed  for  the  fole  purpofe  of 
putting  a  ftop  to  the  difcharge,  by  placing  a  finger 


13^  Of  the  Sarcocele,         Chap.  XXVII* 

upon  every  arten^,  as  foon  as  they  perceive  it  to  be 
cut  ;  nor  Ihould  the  preflure  be  removed  till  the  dif- 
feQion  is  finifhed,  and  the  fiirgeon  in  readinefs  to  fe- 
cure  the  bleeding  veflel  with  a  tenaculum  and  liga- 
ture. This  being  done  over  the  whole  furface  of  the 
fore,  he  next  prc^ceeds  to  tie  the  fpermatic  artery,  and 
to  finilh  the  operation  in  the  manner  I  have  men- 
tioned. 

From  want  of  this  attention,  I  have  known  fuch 
quantities  of  blood  loft,  as  have  either  proved  quickly 
fatal,  or  induced  fuch  debihty  and  relaxation,  as  the 
patient  never  recovered  from  ;  and  as  I  have  in  differ- 
ent inftances  known  even  furgeons  of  experience  fail 
in  the  proper  management  of  this  part  of  the  opera- 
tion, I  think  it  right  to  fay,  that  the  younger  part  of 
the  profeffion  cannot  be  too  much  on  their  guard  in 
performing  it. 

Befides  the  common  form  of  farcocele,  of  which  I 
have  thus  given  an  account,  we  find,  that  in  workers 
among  foot,  the  teftis  is  liable  to  be  attacked  with 
cancer  that  firft  begins  in  the  fcrotum. 

It  firft  appears  on  the  anterior  and  under  part  of 
the  fcrotum,  fometimes  in  the  form  of  a  warty  excref- 
cence,  and  in  others  of  a  foul,  fuperficial  ulcer,  with 
hard  retorted  edges.  From  the  fufpicious  fituation  of 
the  fore,  and  from  the  appearances  which  it  exhibits 
at  firft,  it  is  often  fufpecued  to  be  venereal ;  but  no 
advantage  is  derived  from  mercury,  nor  from  any 
dreflings  that  are  employed.  If  not  prevented  by  ear- 
ly extirpation,  the  ulcer  fpreads  over  the  fcrotum,  and 
from  thence  to  the  teftis,  fpermatic  cord,  and  inguinal 
glands  J  giving  to  the  parts  that  it  attacks  all  the  or- 
dinary and  characleriftic  marks  of  cancer. 

This  variety  of  cancer  appears  obviouily  to  be  pro- 
duced by  foot ;  for  it  is  found,  that,  befides  chimney 
fweeps,  thofe  who  are  employed  in  manufadlures  in 
which  foot  enters  as  an  ingredient,  are  occafionally 
feized  with  it.  And  it  alfo  appears,  that  the  foot  afts 
altogether  locally  in  producing  it  j  for,  when  the  fore 


Chap,  XXVII.         Of  the  Sarcocele.  137 

is  extirpated  early,  that  is,  foon  after  it  has  appeared, 
and  before  it  has  fpread  over  any  great  extent  of  fur- 
face,  the  difeafe  feldoni  returns,  either  there  or  on  any 
other  part. 

As  no  other  remedy  has  been  difcovered,  for  none 
that  I  have  either  tried  or  heard  of  has  any  influence 
in  curing  the  fore,  I  would  therefore  advife  the  difea- 
fed  parts  to  be  extirpated  as  early  as  poflible.  This, 
while  the  ulceration  is  confined  to  the  fcrotum,  is  ea- 
fy  both  to  the  patient  and  furgeon,  when  compared 
with  the  operation  of  caftration,  which  mufl  always 
take  place  when  the  tcflis  becomes  difeafed,  and  is 
therefore  a  ftrong  inducement  for  our  infifting  that  no 
time  fliould  ever  be  loft  in  putting  it  in  pradice, 

I  may  further  obferve,  that  arfenic,  cauftic,  red  pre- 
cipitate, corrofive  fublimate,  and  other  irritating  ap- 
plications, produce  the  fame  cffeds  in  this  as  in  other 
varieties  of  cancer. 

When  applied  fo  as  to  remove  the  difeafed  parts 
entirely,  they  perform  with  much  more  pain,  and  in 
a  much  more  tedious  manner,  what  may  be  more 
neatly  done  by  the  fcalpel  at  once  :  while,  fo  far  as  I 
have  obferved,  none  of  them  are  productive  of  any 
other  advantages,  at  the  fame  time  that,  by  the  irrita- 
tion which  they  excite,  they  very  frequently  do  much 
harm. 

]\Iany  accounts  have  been  communicated  to  the 
public  of  this  and  other  varieties  of  cancer  being  cur- 
ed by  efcharotics  of  different  kinds,  and  chiefly  by  ar- 
fenic, which  appears  to  form  the  bafis  of  a  great  pro- 
portion of  the  remedies  of  this  clafs,  that  have  been 
employed  for  the  cure  of  this  difeafe.  But,  while  all 
of  thefe,  as  well  as  the  internal  ufe  of  hemlock,  and  of 
every  other  medicine  I  have  known  employed,  have 
failed  in  every  inftance,  they  have  very  commonly 
had  the  effedl  of  amufmg  the  patient  with  hopes  of  a 
recovery,  till  it  has  been  too  late  even  for  the  extirpa- 
tion of  the  difeafed  parts  to  prove  fuccefsful. 


13^  Of  the  Sarcocek,         Chap.  XXVII. 

I  have,  therefore,  no  hefitation  in  afferting,  that  the 
operation  fhould  be  advifed  in  the  early  ftages  of  the 
difeafe,  and  that  no  other  remedy,  with  which  we  are 
yet  acquainted,  fhould  ever  be  relied  on. 

Befides  thofe  afFedions  of  the  tefles  and  their  cov- 
erings, that  I  have  defcribed,  there  is  another,  that 
feems  to  be  pecuUar  to  warm  climates.  It  is  met  with 
frequently  on  the  coaft  of  Africa,  and  in  the  Weft  In- 
dies, in  fome  inftances  in  Europeans,  but  chiefly  in 
negroes. 

An  uniform,  firm,  colourlefs  fwelling  attacks  the 
whole  fubftance  of  the  fcrotum.  It  is  feldom,  for  a 
confiderable  time  at  firft,  accompanied  with  pain  ;  but, 
when  it  paifes  from  the  cellular  fubftance  of  the  fcro- 
tum to  the  teftes  themfelves,  which,  in  fome  inftances, 
happens,  it,  in  this  ftate,  always  excites  a  great  deal  of 
diftrefs. 

In  the  early  ftages  of  the  difeafe,  the  external  ap- 
plication of  aftringents,  accompanied  with  a  courfe  of 
mercury,  has,  in  lome  inftances,  proved  ufeful.  But, 
when  the  tumor  has  become  large,  a  cure  has  never 
been  obtained  of  it.  In  this  fituation  the  patient  ob- 
tains no  relief,  but  from  a  proper  application  of  afuf- 
penfory  bag,  and,  in  fevere  degrees  of  pain,  from  largo^ 
dofes  of  opium. 


Seft.  I.  Of  the  Phymojis.  139 

CHAPTER    XXVIII. 

OF  THE  DISEASES  OF  THE  PENIS. 


SECTION    I. 

Of  the  Phymojis, 


THE  glans  penis  is  naturally  provided  with  a  cov- 
ering termed  the  preputium  j  formed  by  an 
elongation  and  doubling  of  the  fkin.  This  in  a  heal- 
thy Hate  is  in  general  of  fuch  dimenfions  as  to  pafs 
eafily  over  the  glans,  but  by  difeafe  it  is  frequently 
prevented  from  doing  fo  ;  and  when  the  prepuce  has 
got  forward,  and  cannot  be  drawn  back  over  the  glans, 
the  difeafe  thereby  produced  is  termed  a  phymofis. 

Phyir.ofis  is  induced  by  whatever  tends  to  fwell  the 
glans,  or  excite  inflammation  and  ftridure  in  the  pre- 
putium :  hence  it  is  a  frequent  confequence  of  gonor- 
rhoea vi'ulenta,  and  lues  venerea ;  and  it  fometimes 
occurs  from  want  of  cleanlinefs,  particularly  in  thofe 
who  are  naturally  liable  to  a  plentiful  exfudation  of 
vifcid  nucus  between  the  glans  and  preputium. 

Whe-e  the  difeafe  is  flight,  and  not  of  long  dura- 
tion, fonenting  the  parts  in  any  warm  emollient  de- 
coftion.  commonly  gives  relief ;  or  what  anfwers  bet- 
ter for  fich  purpofes  than  any  decodion,  is  warm  milk  ; 
this,  together  with  the  ufe  of  emollient  poultices,  with 
a  view  to  relax  the  conftrifted  preputium,  often  an- 
fwers fo  eftedually  as  to  render  other  applications  un- 
neceflTaiy. 

At  tie  fame  time  that  fomentations  and  poultices 
are  advifed,  a  weak  faturnine  folution  fliould  be  injed- 
ed  frcni  time  to  time  between  the  prepuce  and  glans. 


I40  Of  the  Phymofu,         Chap.  XXVIII. 

with  a  fyrlnge,  in  order  to  wafh  away  any  matter  which 
by  its  acrimony  might  tend  to  protract  the  difeafe. 

When  the  parts  are  much  inflamed,  bloodletting 
often  proves  ufeful.  When  the  fuperficial  veins  of  the 
penis  can  be  opened,  any  blood  to  be  difcharged  fliould 
be  taken  from  one  of  them  by  the  lancet ;  but  when 
they  do  not  appear  confpicuous,  taking  blood  from  the 
arm  will  anfwer  as  well  as  from  any  other  part :  local 
bloodletting  with  leeches  would  be  here  particularly 
indicated  ;  but  when  the  difeafe  has  arifen  from  lues 
venerea,  the  bites  of  thefe  animals  almofl:  conftantly 
terminate  in  troublefome  fores.  Together  with  a  dis- 
charge of  blood  proportioned  to  the  ftrength  of  the 
patient,  gentle  laxatives  ihould  be  prefcribed,  a  low 
diet,  and  abflinence  from  exercife. 

When,  however,  it  is  found,  that  even  a  due  perfe- 
verance  in  thefe  means  does  not  remove  the  difeafe, 
and  efpecially  if  chancres  are  confined  under  the  pre- 
puce, which  might  injure  the  glans  by  the  matter  dif- 
charged from  them  not  getting  a  proper  vent,  in  that 
cafe  it  becomes  neceffary  to  remove  the  ftrifture  by  an 
incifion  carried  along  the  whole  courfe  of  th^  prepu- 
tium. 

As  the  fkin  of  the  prepuce  is  exceedingly  Ux,  it  is 
almofl  impofTible  to  cut  it  with  neatnefs  and  accuracy 
in  the  ordinary  way,  either  with  a  fcalpel  or  bi^oury  ; 
and  v\^hen  done  in  this  manner,  the  fkin  yields  b  much 
before  the  inflrument,  as  always  to  render  the  opera- 
tion tedious  and  painful :  neither  are  the  probe  fcilTars 
well  calculated  for  doing  it  properly,  as  the  pats  are 
commonly  fo  much  thickened  by  inflammaticn,  that 
they  cannot  be  rightly  cut  with  fciflars. 

Thefe  inconveniencies  being  obvious,  many  inven- 
tions have  been  propofed  for  doing  the  operatio)i  more 
eafily.  In  Plate  LXVIII.  figures  i.  2.  and  3.  is  re- 
prefented  an  inflrument  which  I  made  for  this  pur- 
pofe  feveral  years  ago,  and  it  anfwers  the  intention 
very  efFeclually,  and  with  much  eafe. 


Se£l.  I.  Of  the  Phymofis,  X4I 

It  confifts  of  a  diredor,  fig.  2.  with  a  fmall  curve 
at  its  extremity,  to  which  a  Iharp  pointed  biftour)'', 
fig.  I.  with  a  narrow  blade,  is  fo  exactly  adapted,  as 
in  fig.  3.  that  the  cutting  part  of  it  is  entirely  conceal- 
ed in  _ the  groove  of  the  director,  which  ought  to  be 
about  a  quarter  of  an  inch  longer  than  the  blade  of 
the  knife. 

The  knife  being  inferted  into  the  director,  fo  as  to 
be  covered  by  it  entirely,  the  inftrunient  in  this  ftate 
is  to  be  pafl'ed  between  the  prepuce  and  glans  on  one 
fide  of  the  penis,  till  the  director  is  found  by  the  fin- 
ger to  have,  reached  the  upper  end  of  the  preputlum. 
The  operator  is  now  to  keep  the  director  firm  with 
one  hand,  and  with  the  other  is  to  pufli  the  knife  for- 
ward, lb  as  to  make  its  point  pafs  through  the  pre- 
puce ;  and  the  director  being  withdrawn,  the  opera- 
tion is  finiflied  by  drawing  the  knife  forward,  fo  as  to 
make  it  divide  the  prepuce  through  its  whole  length 
along  the  fide  of  the  penis. 

In  this  manner  the  preputium  Is  preferved^  in  a  tenfe 
flate,  while  the  divifion  is  going  on,  by  which  means 
the  operation  is  accompliflied  with  eafe :  and,  by  di- 
viding the  preputium  on  one  fide,  we  more  readily 
avoid  the  large  veins  of  the  penis,  at  the  fame  time 
that  the  matter  proceeding  from  the  cut  is  more  eafi- 
ly  difcharged,  than  when  the  operation  is  done  on  the 
back  part  of  the  penis. 

The  prepuce  being  thus  divided,  the  parts  fliould 
be  bathed  with  warm  water,  fo  as  to  wafh  off  any  ac- 
rid matter  with  which  they  may  be  covered  ;  and  this 
being  done,  the  fore  fhould  be  covered  with  foft  lint ; 
and  a"  comprefs  of  old  linen  being  laid  over  it,  the 
whole  may  be  eafily  retained  by  a  fmall  linen  bag 
adapted  to  the  fize  of  the  penis,  to  be  fecured  by  two 
ftraps  pinned  to  a  circular  bandage  made  to  furround 
the  body.  This  bag  muft  indeed  be  always  removed 
when  the  patient  makes  v/ater  ;  but  this  is  eafily  done  ; 
and  it  retains  the  dreflinsfs  not  onlv  more  efieduallv, 


143  Of  the  Paraphpmfis.       Chap.  XXVIH. 

but  with  more  eafe  to  the  patient,  than  is  done  either 
with  adhefive  plafters  or  any  other  form  of  bandage. 

In  the  after  dreffings  of  the  fore,  care  fliould  be 
taken  to  infert  a  piece  of  foft  Hnt  between  the  divided 
prepuce  and  glans,  otherwife  troublefome  adhefions 
are  apt  to  take  place.  I  have  met  with  feveral  inftan- 
ces  of  this,  which  gave  much  diflrefs  to  the  patients, 
and  which  with  due  care  and  attention  in  drefling  the 
fores,  might  eafily  have  been  prevented. 

It  is  fcarcely  neceffary  to  obferve,  that  when  any 
venereal  infeftion  fubfifls  in  the  conflitution,  the  fore 
produced  by  this  operation  will  not  readily  heal,  if 
the  patient  be  not  put  under  mercury.  In  fuch  cir- 
cumftances,  therefore,  if  mercury  has  not  been  previ- 
oully  given,  it  ought  always  to  be  advifed  immediate- 
ly on  the  operation  taking  place. 

In  fome  cafes  of  phymofis,  the  preputium  is  fo  long 
that  the  operation  of  circumcifion  anfwers  the  purpofe 
better  than  a  longitudinal  cut.  And  it  is  eafily  done, 
by  taking  away  all  the  fuperabundant  portion  of  the 
prepuce  by  one  flroke  of  a  fcalpel.  It  fometimes, 
however,  happens,  when  the  operation  is  done  in  this 
manner,  that  the  remainder  of  the  preputium  con- 
tracts fo  powerfully,  as  to  produce  a  good  deal  of  dif- 
trefs  ;  which  can  only  be  obviated  by  due  attention  to 
the  after  treatment  of  the  fore,  and  making  ufe  of 
emollients,  inftead  of  aflringent  applications  during 
the  cure. 


SECTION    II. 

Of  the  Faraphpiofis. 

BY  the  term  paraphymofis  is  meant  a  morbid  re- 
traftion  of  the  preputium,  producing  flridturc 
behind  the  glans  penis.  This  difeafe,  like  the  former, 
is  a  frequent  fymptom  in  the  venereal  difeafe :  but  it 


Sed.  II.  Of  the  Paraphymofis,  143 

will  arlfe  from  whatever  tends  to  produce,  either  a 
preternatural  fulnefs  in  the  glans,  or  a  conftridion  of 
the  prepuce  ;  and  more  efpecially  from  fuch  caufes  as 
induce  a  complication  of  both. 

In  the  incipient  ftate  of  paraphymofis,  we  may  oft- 
en with  due  dexterity  and  attention  bring  the  prepuce 
over  the  glans,  by  pufhing  the  glans  gently  back  with 
the  thumb  of  each  hand,  while  with  the  fingers  we 
draw  the  prepuce  eafily  forward.  In  the  more  ad- 
vanced ftate  of  the  difeafe,  however,  no  attempt  of  this 
kind  fhould  be  advifed,  as  it  is  in  its  commencement 
only  that  it  ever  fucceeds ;  and  when  it  does  not  prove 
ufeful,  it  is  apt  to  do  harm,  by  inducing  an  increafed 
degree  of  irritation  in  the  parts  to  which  the  prelfure 
is  applied. 

As  the  paraphymofis  feems  to  be  more  frequently 
induced  by  an  enlargement  of  the  glans  than  by  any 
original  affection  of  the  prepuce,  fo  the  ftriclure  in  the 
prepuce  is  not  here  fo  completely  relieved  by  emollient 
fomentations,  as  it  commonly  is  in  phymofis,  where 
the  difeafe  is  moft  frequently  produced  by  a  ftridlure 
of  the  prepuce  alone.  In  paraphymofis,  indeed,  warm 
emollients  feem  rather  to  do  harm,  as  they  tend  evi- 
dently to  increafe  the  fwelling  in  the  glans,  by  which 
the  ftriclure  in  the  prepuce  is  always  proportionally 
increafed. 

Nothing  in  general  anfwers  fo  well  here  as  fatumine 
appUcations.  The  fwelling,  indeed,  will  often  fubfide 
by  being  frequently  immerfed  in  a  cold  folution  of 
faccharum  faturni,  when  all  other  remedies  fail.  But, 
when  the  penis  is  evidently  much  fvvelled  and  inflam- 
ed, together  with  this  application  to  the  part,  the  pa- 
tient fhould  be  kept  cool ;  gentle  laxatives  fliould  be 
prefcribed,  and  blood  be  taken  from  one  of  the  fuper- 
ficial  veins  of  the  penis. 

By  due  perfeveraiice  in  thefe  means,  and  keeping 
the  patient  on  low  diet,  the  ftridure  is  frequently  re- 
moved. But,  when  the  difeafe  proceeds  to  increafe, 
by  the  fwelling  iu  the  glans  becoming  more  confider- 


144  Of  the  Paraphymofis.       Chap.  XXVIIL 

able,  and  the  ftriclure  of  the  prepuce  increafmrr,  the 
preputium  becomes  cedcmatous,  and  unlefs  relief  be 
foon  obtained  by  a  complete  removal  of  the  ftridlure, 
gangrene  of  the  glans  very  commonly  enfues. 

When,  therefore,  none  of  the  remedies  I  have  men- 
tioned anfwer  the  purpofe,  we  fhould  endeavour  to  re- 
move the  ftriclure  by  an  operation ;  and  the  eafieft 
method  of  performing  it  is,  with  the  flioulder  of  a  lan- 
cet, or  a  fmall  fcalpel  or  biftoury,  to  make  a  deep  fcar- 
ification  on  each  fide  of  the  penis,  directly  behind  the 
glans  ;  taking  care  to  make  each  cut  of  about  half  an 
inch  in  length,  and  of  fuch  a  depth  as  effectually  to 
divide  the  prepuce  juft  at  the  fpot  where  the  ftridure 
is  moft  confiderable. 

The  parts  fhould  now  be  allowed  to  bleed  freely, 
as  ^is  circumftance  of  itfelf  in  general  affords  relief ; 
and  as  foon  as  the  flow  of  blood  is  over,  a  pledget  of 
any  emollient  ointment  being  applied  to  the  fores,  and 
a  foft  well  made  poultice  being  laid  over  the  whole,  if 
the  fcarifications  have  been  carried  entirely  through 
the  ftridure,  nothing  further  will  be  neceffa'ry  than 
dreffing  the  parts  daily  with  the  fame  ointment  with 
which  they  were  at  firft  covered  :  but,  if  the  fcarifica- 
tions have  not  been  made  of  a  fufficient  depth,  it  may 
afterwards  be  neceffary  to  renew  them  ;  \^'hen  care 
muft  be  taken  that  they  are  effedually  done. 

In  the  phymofis,  I  advifed  the  patient  to  be  put  un- 
der a  mercurial  courfe  whenever  there  is  reafon  to  fuf- 
pect  that  he  is  infected  with  lues  venerea ;  and  the 
fame  precaution,  it  is  evident,  is  equally  proper  in  pa- 
raphymofis. 


Se6t.  III.         Amputation  of  the  Pails,  I45 

SECTION    III. 

Of  A?nputat'w}i  of  the  Penis,  ^c, 

THE  penis,  like  other  parts  of  the  body,  is  h'able 
to  dircafes,  which  in  fome  inflances  render  am- 
putation neceffary. 

Thus,  in  fome  inflances,  it  is  attacked  with  gangrene, 
and  in  others  with  cancer,  in  both  of  which  amputa- 
tion is  very  commonly  requifite. 

I  have  elfewhere  entered  fully  into  the  confideration 
both  of  mortification  and  cancer.*  Referring,  there- 
fore, to  the  obfervations  that  I  had  there  occafion  to 
fuggeft,  I  fhall  at  prefent  only  advert  to  the  mode  of 
amputating  the  penis  when  it  becomes  fo  difeafed  as  to 
render  this  operation  neceffary. 

A  circular  incifion  fliould  be  firft  made  through  the 
found  fkin  at  the  upper  end  of  the  difeafed  parts,  when 
the  flvin  being  drawn  back  by  an  affiftant,  the  body 
of  the  penis  fhould  be  cut  through  by  one  ftroke  of 
the  fcalpel,  care  being  taken  to  remove  every  part  that 
appears  to  be  difeafed. 

This  being  done,  fuch  arteries  as  bleed  freely  fhould 
be  carefully  fearched  for,  and  fecured  with  ligatures. 
In  general,  two,  and  fometimes  three  arteries  are  met 
with  J  and  they  fliouId  all  be  fecured  in  this  manner. 
But  even  after  the  principal  arteries  have  been  tied,  a 
confiderable  oozing  of  blood  ufually  continues  from 
the  furface  of  the  fore,  which  we  fometimes  flop  by 
fprinkling  the  whole  with  flarch  or  gum  arable  in  fine 
powder  ;  but  when  this  does  not  anfvver,  a  fmall  filver 
canula  being  paffed  into  the  urethra,  and  retained  with 
a  bandage,  any  farther  difcharge  of  blood  may  be  ea- 
fily  flopped  by  flight  compreffion  with  a  narrow  roU- 

•  Vide  Chap.  I.  ScO.  IV.  aad  Cijap.  V-  Sctft.  VIII. 

Vol.  III.  L 


14^  Amputailon  of  the  Penis.     Chap.  XXVlH. 

er  on  the  parts  that  remain.  A  flight  degree  of  com- 
preilion  anfwcrs  the  purpofe,  fuch  a  degree  of  it,  in- 
deed, as  does  not  hurt  the  parts  on  which  it  is  made  ; 
and  as  the  tube  inferted  into  the  urethra  need  not  be 
long,  it  is  eafily  retained  during  the  whole  courfe  of 
the  cure,  without  either  inconvenience  or  diftrefs. 

In  Plate  LXVI.  fig.  4.  is  reprefented  a  tube  which 
I  have  in  different  inftances  ufed  for  this  purpofe.  It 
is  eafily  kept  in  its  fituation  by  fixing  it  with  two  lig- 
atures, one  on  each  fide,  to  a  narrow  roller  round  the 
penis. 

Heifler,  as  well  as  others,  being  afraid  of  the  he- 
morrhagy  produced  by  amputating  the  penis,  advife 
it  to  be  done  with  a  flrong  ligature,  A  ligature  be- 
ing applied  with  firmnefs  above  the  difeafed  parts,  they 
are  thereby  made  to  fall  off  in  the  courfe  of  fix  or  eight 
days  ;  but  whenever  a  part  can  be  eafily  removed  with 
the  fcalpel,  it  is  done  with  much  more  eafe  and  expe- 
dition than  in  any  other  manner. 

Others,  again,  have  faid,  that  no  danger  is  to  be 
dreaded  from  any  difcharge  of  blood  that  can  ever  en- 
fue  from  amputating  the  penis  ;  but  this  I  know  from 
experience  is  not  the  cafe.  In  the  courfe  of  a  few 
months,  I  had  occafion  to  perforin  this  operation  three 
different  times  in  the  Royal  Infirmary  here  ;  and,  in 
the  firfl,  I  was  perfuaded  by  a  gentleman  who  had 
found  it  in  one  cafe  to  fucceed,  not  to  fecure  the  ar- 
teries with  ligatures,  but  to  truft  to  compreffion  alone. 
This  was  accordingly  done  ;  but  unfortunately,  in  the 
courfe  of  an  hour  or  two  after  the  operation,  fuch  a 
profufe  hemorrhagy  fupervened  as  terminated  in  the 
patient's  death. 

In  the  next,  I  was  refolved  to  fecure  every  branch 
of  an  artery  that  could  be  laid  hold  of.  Three  differ- 
ent arteries  were  accordingly  tied,  and  no  hemorrhagy 
enfued.  In  the  third  operation,  two  branches  of  an 
artery  were  fecured  ;  but  a  plentiful  oozing  ftill  con- 
tinuing from  the  fore,  the  filver  tube  above  mention- 
ed was  introduced  into  the  urethra,  and  a  flight  com- 


■%, 


Se£l.  III.         A?npuiation  of  the  Penis.  147 

preflion  being  made  upon  it,  the  difcharge  was  imme- 
diately flopped.  In  no  other  inftance  of  my  perform- 
ing this  operation  did  any  dangerous  hemorrhagy  take 
place,  and  1  have  done  it  in  a  great  many. 

When  all  the  arteries,  for  we  frequently  meet  with 
three  or  four,  have  been  fecured  in  this  manner,  the 
parts  fliould  be  covered  with  pieces  of  foft  lint  fprink- 
led  with  ftarch  or  gum  arable  in  powder  ;  and  a  com- 
prcfs  of  linen,  with  a  hole  in  it  large  enough  to  pafs 
over  the  canula  in  the  urethra,  being  laid  over  it,  and 
the  T  bandage  being  employed  to  retain  it,  all  the 
dreflings  may  in  this  manner  be  fecured  ;  while  the 
after  treatment  of  the  fore  fliould  be  fimilar  to  that 
of  wounds  in  any  other  part. 

In  proceeding  to  this  operation,  It  ought  to  be  kept 
in  view,  that  the  prepuce  is  frequently  fo  much  en- 
larged and  ulcerated,  as  to  give  caufe  to  fufpeft  that 
the  glans  as  well  as  the  reft  of  the  penis  is  difeafed, 
when  in  reality  they  are  perfedly  found.  I  was  once 
prefent  at  an  operation,  where  the  previous  appear- 
ances were  fuch  as  gave  no  reafon  to  doubt  of  the 
glans  being  difeafed  ;  the  prepuce,  with  part  of  the 
penis,  was  accordingly  taken  off;  when  it  afterwards 
appeared  that  the  glans  might  have  been  faved,  as  the 
dil'eafe  was  found  to  be  confined  to  the  prepuce  alone. 

In  every  cafe,  therefore,  where  we  are  not  abfolute- 
ly  certain  of  the  glans  being  affeded,  all  the  difeafed 
preputlum  fliould  be  firfl  renioved  ;  and  the  flate  of 
the  parts  below  being  examined,  if  they  are  found  to 
be  fo  much  difeafed  as  to  render  it  proper  to  remove 
them,  it  can  be  then  done  with  as  much  eafe  as  if  they 
had  been  taken  off  along  with  the  prepuce  ;  while,  on 
the  contrary,  when  they  appear  to  be  found,  the  fur- 
geon  as  well  as  the  patient  will  have  much  caufe  to 
rejoice. 

It  fometimes  happens,  that  the  frenum  penis  is  fo 
fliort  as  to  excite  much  uneafmefs  when  the  parts  are 
in  a  ftate  of  eredion.  But  as  no  danger  enfues  from 
L  2 


143  Ampuiaiion  of  the  Penh.      Chap.  XXVIII. 

a  divlfion  of  this  ligament,  whenever  it  proves  trouble- 
fome,  it  ought  to  be  cut  acrofs  ;  and  it  is  eafily  done 
with  probe  pointed  fciflars  :  after  the  frenum  is  divid- 
ed, a  bit  of  foft  lint  fliould  be  inferted  between  the 
lips  of  the  wound,  otherwife  the  parts  newly  feparated 
will  be  apt  to  reunite. 

In  fome  inflances,  the  urethra  in  male  children  i$ 
incomplete,  and  terminates  before  it  reaches  the  point 
of  the  yard.  In  others  no  external  opening  can  be 
difcovered,  while  in  many  the  urethra  terminates  in  a 
fmall  opening,  not  large  enough  to  admit  a  fmall  pin 
head,  at  fome  diftance  from  the  end  of  the  penis. 

When  no  opening  is  difcovered,  if  the  urine  is  found 
to  flop  at  any  particular  part,  the  introduction  of  a 
fmall  trocar  from  the  point  of  the  yard  along  the  courfe 
that  the  urethra  ought  to  take,  and  carrying  it  for- 
ward till  it  meets  with  the  urine,  will  give  immediate 
relief ;  and  by  the  ufe  of  fmall  bougies,  the  fides  of 
the  paflage  may  be  rendered  callous,  and  a  clear 
opening  preferved.  But  when  any  opening  is  difcav- 
ered,  although  it  Ihould  not  be  properly  placed,  if  it 
affords  a  temporary  paffage  to  the  urine,  it  is  better  to 
delay  the  operation  till  the  patient  is  advanced  in  life ; 
and  on  an  opening  being  then  made  with  a  trocar  in 
the  manner  I  have  mentioned,  a  piece  of  flexible  ca- 
theter of  refina  elaflica  may  be  introduced,  not  only 
for  preferving  the  paffage  free  and  pervious,  but  for 
carrying  off  the  water  till  a  cure  is  obtained.  In  the 
earlier  periods  of  childhood,  the  fmallnefs  of  parts 
through  which  a  catheter  ought  to  pafs,  renders  the 
ufe  of  this  inflrument  altogether  inadmiffible. 

Befides  the  affedions  of  the  penis  that  we  have  been 
juft  confidering,  fiftulous  openings  frequently  form  in 
the  urethra,  and  they  always  give  much  diftrefs.  Thefe- 
however,  as  well  as  the  treatment  of  flones  impacted 
in  the  urethra,  will  fall  to  be  confidered  hereafter. 


Se£l:»  L  Of  the  Stone,  149 

CHAPTER    XXIX. 
Of  the  stone. 

SECTION    I. 

General  Remarks  on  Urinary  Calculi. 

PARTICLES  of  Hone  have  been  known  to  form 
in  almoft  every  cavity  of  the  body,  but  more 
frequently  in  the  organs  of  urine  than  in  other  parts. 

The  blood,  as  well  as  the  fecretions  which  it  af- 
fords, are,  by  experiment,  found  to  contain  a  large 
proportion  of  earth  :  when  this  earthy  part  of  our 
fluids  is  in  the  ufual  quantity,  and  when  not  feparated 
by  difeafe,  it  continues  to  circulate  along  with  the 
other  parts  of  which  thefe  fluids  arc  compofed  ;  and 
in  this  fl;ate  no  harm  ever  enfues  from  it.  Various 
caufes,  however,  may  concur  to  produce  a  depofition 
of  this  earthy  matter  from  the  blood  and  its  fecre- 
tions. 

I.  We  know,  that  every  liquid  can  diflblve  and 
keep  fufpended  a  certain  quantity,  and  no  more,  of 
thofe  fubftances  of  which  it  is  a  menilruum  ;  and  it 
is  likewife  known,  when  a  greater  proportion  than 
this  is  added,  that  a  feparation  and  coniequent  depo- 
fition takes  place  of  all  the  additional  quantity.  In 
like  manner,  we  may  fuppofe,  if  the  ladeal  veflTels 
ever  abforb  a  greater  proportion  of  earthy  matter  from 
the  contents  of  the  inteliines,  than  the  quantity  of  flu- 
ids in  the  circulating  fyftem  can  keep  fufpended,  that 
this  fuperabundance  of  earth  muft  necelTarily  feparate 
from  the  reft  ;  and  the  depofitions  thus  produced  are 
much  more  likely  to  occur  in  the  bladder  and  kid- 
neys than  in  other  parts,  from  the  urine  containing  a 
larger  proportion  of  earth  than  any  other  fecretion. 


150  Of  the  Stone,  Chap.  XXIX, 

2.  Independent  of  other  caufes  which  miy  tend  to 
induce  a  fuperabundant  quantity  of  earthy  matter  in 
the  blood,  fuch  articles  of  food  as  contain  a  large  pro- 
portion of  earth  have  been  fuppofed  to  be  more  pro- 
ductive of  it  than  others  :  but  unlefs  fuch  quantities 
of  earth  as  are  contained  in  food,  be  conveyed  in  a 
ftate  of  the  mofl  perfect  folution,  any  effect  that  may 
refult  from  it  will  not  be  important.  There  is  much 
reafon,  however,  to  think,  that  a  long  continued  ufe, 
either  of  water,  or  of  wines  abounding  with  earth  in 
a  diffolved  ftate,  has  a  confiderable  tendency  to  pro- 
duce that  ftate  of  the  blood  to  which  I  allude  ;  of 
which  indeed,  I  could  produce  various  facts  that  could 
not  admit  of  difpute. 

3.  Thofe  who  are  much  accuftomed  to  the  ufe  of 
folid  food,  will  be  more  liable  to  the  formation  of  a 
large  proportion  of  earthy  matter  in  the  blood,  than 
thofe  who  by  a  free  ufe  of  liquids  are  in  the  habit  of 
preferving  a  more  plentiful  and  more  diluted  ftate  of 
the  fecretions.  And  accordingly,  in  thofe  who  fre- 
quently void  particles  of  fand,  and  even  fmall  calculi, 
I  have  known  more  advantages  derived  from  a  con- 
tinued and  plentiful  ufe  of  diluent  drinks,  than  from 
any  other  remedy.  A  hberal  ufe  of  watery  fluids 
may,  no  doubt,  operate  to  much  advantage,  by  wafti- 
ing  away  particles  of  fand  and  ftone  already  formed 
and  lodged  in  fome  of  the  organs  of  urine  ;  but  they 
feem  hkewife  to  prove  ufeful,  merely  by  their  diluent 
properties  in  preventing  their  formation, 

4.  A  fuperabundance  of  earthy  matter  being  once 
produced  in  the  blood,  various  circumftances  may 
concur  to  form  depofitions  of  it  in  the  different  cavi- 
ties :  of  thefe  a  fedentary  life  is,  perhaps,  one  of  the 
moft  remarkable  ;  and  hence  it  probably  is,  that  fuch 
people  are  found  to  be  moft  liable  to  calculous  com- 
plaints, whofe  occupations  require  the  leaft  bodily  ex^ 
ertion. 

It  muft  indeed,  be  allowed,  that  ftone  in  the  blad^ 
der  is  frequently  met  with  amongft  indigent  and  in-? 


Sea.  I.  Of  the  Stone.  151 

duftrious  labourers  ;  whofe  neceflities,  at  all  times, 
prevent  their  indulging  in  indolence.  In  fuch  inftan- 
ces,  however,  it  may  be  fuppofed,  that  the  very  coarfe 
articles  of  food,  with  which  people  in  this  line  of  life 
are  chiefly  nourifhed,  will  tend  to  impregnate  the 
blood  with  fuch  a  large  proportion  of  earth,  as  mull 
neceflarily  produce  eflecls  not  to  be  obviated,  even  by 
the  beneficial  influence  of  a  continued  and  regular 
courfe  of  exertion. 

5.  Whatever  influence  a  predifpofitlon  in  the  fyf^ 
tem  may  have  in  the  formation  of  calculus,  and  in  its 
fubfequent  increafe  of  bulk,  the  introduction  of  any 
fubfl:ance  that  can  ferve  as  a  nucleus,  will  almofl:  cer- 
tainly produce  a  (lone,  in  whatever  cavity  it  is  lodg- 
ed. Thus,  a  particle  of  fand,  of  blood,  or  coagulable 
lymph,  may  in  confequence  of  fpafm  or  inflammation, 
be  confined  in  the  pelvis  of  one  of  the  kidneys,  or  in 
the  cavity  of  the  bladder,  and  may  foon  acquire  fuch  a 
fize,  from  the  conflant  addition  of  earthy  matter  that 
it  receives,  as  to  make  it  impofllble  for  the  urine  to 
carry  it  off:  and  urinary  calculi,  thus  begun  to  be 
formed,  will  acquire,  fooner  or  later,  a  confiderable 
bulk,  according  to  the  quantity  of  earth  with  which 
the  urine  is  impregnated.  Thus  inft:ances  have  oc- 
curred, of  flones  becoming  large,  in  the  fpace  of  a 
few  months  from  the  firfl  obvious  fymptoms  which 
they  produce  ;  while  at  other  times,  they  have  been 
known  to  remain  in  the  bladder  for  a  great  many 
years,  without  arriving  at  any  fize  of  importance. 

When  fpeaking  of  nuclei,  it  is  necefl'ary  to  remark, 
that  their  eft'efl;  in  the  formation  of  calculi,  in  the  uri- 
nary paffages  efpecially,  appears  to  be  fo  great,  that  it 
may  be  doubted  whether  a  Itone  is  ever  known  to 
form  in  thefe  parts  without  the  intervention  of  this 
caufe  ;  for,  however  large  the  quantity  of  earth  con- 
tained in  urine  may  be,  it  would  probably  all  flow  off 
by  the  urethra,  if  it  was  not  detained  by  the  acciden- 
tal introdudion  or  formation  of  a  nucleus, 


1^2  Of  the  Stone,  Chap.  XXIX. . 

Nuclei  of  different  kinds,  fuch  as  hairs,  needles, 
mulket  and  piflol  bullets,  pieces  of  bougies,  and  a 
variety  of  other  articles,  have  been  met  with  in  the 
centre  of  urinary  calculi ;  but  particles  of  blood,  or  of 
coagulable  lymph,  are  moft  frequently  found  to  pro- 
duce them. 

By  the  difference  of  food  ufed  at  different  periods 
of  the  difeafe  ;  by  the  ftone  being  formed  flowly  or 
more  quickly  ;  and  perhaps,  by  the  intervention  of 
other  caufes  which  are  not  always  known,  and  which 
if  known,  could  not  be  eafily  explained  ;  it  common- 
ly happens,  that  the  different  lamellse  of  which  hu- 
man calculi  are  compofed,  vary  confiderably  both  in 
colour  and  confiftence  ;  a  crufi  of  a  foft  friable  na- 
ture being  frequently  known  to  cover  one  of  a  tex- 
ture equal  in  hardnefs  to  the  moft  folid  marble  ;  while 
this  again  is  found  to  furround  a  ftratum  not  firmer 
than  a  piece  of  dough. 

Whatever  may  be  the  Immediate  caufe  of  this  dif- 
ference of  confiftence  in  ftones,  and  even  of  different 
parts  of  the  fame  ftone,  is  of  little  importance  in  prac- 
tice :  but  we  know  from  experience,  that  the  fymptoms 
produced  by  calculi  formed  of  hard  compaQ:  materi- 
als, are  in  general  more  fevere  than  fuch  as  arife  from 
thofe  of  a  fofter  texture  ;  and  we  likewife  know,  that 
the  furface  of  ftones  being  fmooth  or  ragged,  has 
much  more  influence  than  any  other  circumftance  in 
the  violence  of  the  fymptoms  which  they  produce  : 
much  variety  too,  it  may  be  remarked,  is.  met  with  in 
human  calculi  with  refpeft  to  the  fmoothnefs  of  their 
furfaces  ;  fome  being  perfectly  polifhed,  while  others 
are  covered  with  hard  fharp  points. 

The  violence  of  fymptoms  in  this  difeafe,  Is  com- 
monly in  proportion  to  the  fize  of  the  ftone  ;  ftones 
of  the  greateft  bulk  being  for  the  moft  part  attended 
with  the  moft  fevere  pain.  This,  however,  is  not  al- 
ways the  cafe  ;  for  inftances  fometimes  occur  of  the 
moft  fevere  fymptoms  being  induced  by  fmall  ftones ; 
whiljl  in  others,  ftones  of  a  confiderable  fize  have 


J 


Sea.  I.  Of  ihe  Stone.  153 

been  known  to  fubfifl  for  a  great  length  of  time  with- 
out inducing  much  pain :  but  in  general  it  is  other- 
wife,  and  the  fymptoms  are  moft  frequently  mild  or 
fevere,  according  as  the  flone  by  which  they  are  pro- 
duced is  fmall  or  large. 

When  a  flone  has  acquired  fuch  a  fize  that  it  can- 
not pafs  off  from  the  bladder,  the  patient  becomes  lia- 
ble to  fymptoms  which  froni  their  commencement 
give  much  uneafmefs,  and  which,  in  the  event,  com- 
monly terminate  in  the  mofl  afllicting  fcenes  of  diflrefs 
to  which  the  human  frame  is  liable. 

One  of  the  firfl  fymptoms  of  flone,  is  an  uneafy 
fenfation  at  the  point  of  the  yard,  which  for  fome  time 
is  only  difcovered  on  the  patient  taking  violent  and 
jolting  exercife,  or  immediately  after  voiding  urine. 
This  pain  by  degrees  becomes  more  frequent  and 
more  fevere.  The  patient  has  a  flrong  propenfity  to 
pafs  urine  frequently,  and  commonly  voids  it  in  fmall 
quantities,  perhaps  even  drop  by  drop. 

When  flowing  in  a  full  flream,  it  often  flops  fud- 
denly  ;  and  this  it  is  moft  apt  to  do  when  a  confider- 
able  quantity  is  collected,  and  when  of  courfe  the 
patient's  defire  for  voiding  it  is  Urongefl.  Nor  does 
the  preflure  ufually  made  by  the  patient  anfwer  any 
good  purpofe  :  for,  as  the  interruption  to  the  flow  of 
urine  proceeds  from  the  weight  of  the  flone  bearing 
againfl  the  neck  of  the  bladder  and  orifice  of  the  ure- 
thra, nothing  will  produce  a  free  i*eturn  of  it  but  an. 
alteration  in  the  fite  of  the  flone,  which  more  readily 
happens  from  the  patient  changing  the  poflure  of  his 
body,  and  particularly  by  the  pelvis  being  more  or 
lefs  elevated,  than  by  all  the  preifure  that  he  can  em- 
ploy for  forcing  it  out. 

The  urine  of  calculous  patients  is  often  perfectly 
clear,  but  mofl  commonly  thick,  and  dcpofites  a  mu- 
cous fediment ;  and  not  unfrequently,  when  the  dif- 
eafe  is  violent,  and  the  paroxyfms  frfequent  In  their 
return,  it  is  tinged  with  blood.  When  the  flone  is 
large,  a  dull  uneafy  fenfation  takes  place  about  the 


154  Of  the  Stone,  Chap.  XXIX. 

neck  of  the  bladder  ;  and  the  irritation  produced  by 
it  frequently  excites  a  tenefmus,  or  a  conftant  and 
painful  defire  to  go  to  ftool. 

All  thefe  fymptoms  are  commonly  increafed  by  ex- 
«rcife,  particularly  by  riding  on  horfeback  ;  and  from 
a  long  continuance  of  pain,  and  from  that  want  of  reft: 
which  frequent  returns  of  the  paroxifms  induce,  the 
patient's  ft:ate  of  health  by  degrees  becomes  impaired  ; 
and  unlefs  the  ftone  is  removed,  it  commonly  hap- 
pens that  his  mifery  is  only  terminated  by  death. 

When  all  or  moft:  of  the  fymptoms  that  I  have 
enumerated,  occur  in  the  fame  patient,  there  can  be 
no  great  reafon  to  doubt  of  the  caufe  by  which  they 
are  produced  ;  and  we  know  with  certainty  that  they 
proceed  from  calculus,  when  fragments  of  ftone,  or 
fundry  fmall  fl:ones,  continue  to  pafs  from  time  to 
time  along  with  the  urine  :  but  when  this  does  not 
occur,  we  can  never  with  certainty  know  whether  the 
fymptoms  arife  from  ftione  or  not ;  for  inftances  fre- 
quently happen,  of  all  the  fymptoms  ufually  produced 
by  ftione  in  the  bladder,  arifmg  from  an  ulcer  or  tu- 
mor either  in  the  bladder  itfelf,  or  in  its  neck,  or  even 
from  tumors  on  the  contiguous  parts  when  they  prefs 
either  on  the  bladder  or  on  its  neck. 

Pra£titioners  accuftomed  to  this  branch  of  pra£tice, 
will  in  general  be  able  to  judge  from  the  fymptoms, 
whether  a  ftione  actually  exifts  in  the  bladder  or  not ; 
but  the  only  certain  means  by  which  it  can  be  afcer- 
tained,  is  through  the  intervention  of  a  found  or  curv- 
ed probe  ;  different  fizes  of  which  are  reprefented  in 
Plate  LXIX.  By  pafting  this  inftirument  into  the 
bladder,  in  the  manner  I  fhall  prefently  mention,  if  it 
touches  a  ftione,  fuch  a  fenfation  is  thereby  communir 
cated  to  the  operator,  as  gives  ample  convidion  of 
the  real  caufe  of  the  difeafe. 


Sea.  II.  Of  the  Stone.  155 

SECTION    II. 
Of  Sounding  or  Searching  for  the  Stone. 

BEFORE  defcribing  the  operation  of  founding,  it 
will  be  proper  to  give  an  anatomical  dcfcription. 
of  fuch  parts  as  are  concerned  in  it ;  and  to  this  I 
fhall  add  an  account  of  thofe  parts  that  are  mod  im- 
mediately injured  by  the  various  operations  of  lithoto- 
my :  thefe  are,  the  kidneys,  ureters,  urinary  bladder, 
pelvis,  veficulse  feminales  and  their  dudls,  proflate 
gland,  urethra,  penis,  fome  of  the  mufcles  of  the  penis, 
and  part  of  the  abdominal  mufcles. 

A  minute  defcription  of  thefe  parts  would  lead  to 
an  extenfive  difcuiTion,  inconfiftent  with  the  nature  of 
this  undertaking ;  and  as  fuch  a  defcription  is  not  ne- 
ceflary,  I  fliall  only  give  fuch  an  account  of  the  parts 
as  may  ferve  to  render  intelligible  the  defcription  to  be 
afterwards  given  of  the  operations  to  be  performed  on 
them. 

The  kidneys  are  two  glandular  bodies  lying  in  the 
back  part  of  the  abdomen,  on  the  upper  part  of  the 
pfose  mufcles  ;  the  right  being  feated  immediately  be- 
low the  great  lobe  of  the  liver,  and  the  left  under  th^e 
fpleen  ;  and  they  are  both,  I  may  remark,  almoll  com- 
pletely covered  by  the  flight  curvatures  of  the  inferior 
falfe  ribs.  They  are  fupplied  with  blood  veflbls,  term- 
ed the  emulgent  arteries  and  veins,  dire6tly  from  the 
trunks  of  the  aorta  and  vena  cava.  The  ufe  of  thefe 
organs  is  to  feparatc  the  urine  from  the  blood,  which, 
as  foon  as  it  is  fecreted,  is  carried  by  means  of  two 
canals  or  tubes,  one  from  each  kidney,  termed  the 
ureters,  direftly  to  the  vefica  urinaria.  The  ureters, 
after  leaving  the  kidneys,  proceed  obliquely  downwards 
behind  the  fpermatic  velfels,  over  the  os  facrum  ;  and 
palling  in  between  the  bladder  and  reftum,  they  are 
jnferted  into  the  former  near  to  its  neck,  at  a  fmall 


156  Of  the  Sfotif.  Chap.  XXIX. 

diftance  from  one  another ;  and  after  piercing  the  ex- 
ternal coat  of  the  bladder,  they  run  obliquely  for  a 
ihort  fpace  between  it  and  the  more  internal  covering 
of  that  organ  before  penetrating  its  cavity  :  a  conftruc- 
tion  well  calculated  for  preventing  a  reflux  of  lyrine  to 
the  kidneys. 

The  pelvis  is  a  kind  of  box  or  bafon,  formed  by  a 
Conjundion  of  the  os  facrum,  os  coccyx,  and  oiTa  in- 
nominata.  The  cavity  formed  by  a  particular  combi- 
nation of  thefe  parts,  being  intended  for  the  protec- 
tion of  the  bladder,  and  fome  other  organs,  is  every 
where  furrounded  with  bone,  or  with  ftrong  ligaments, 
except  at  its  upper  and  inferior  parts,  where  alone  the 
pelvis  is  accefTible,  being  here  covered  with  foft  parts 
only.  The  cavity  of  the  pelvis  is  chiefly  occupied  by 
the  bladder,  which,  when  in  a  dillended  ftate,  fills  it 
entirely,  and  even  afcends  confiderably  above  its  brim. 

The  bladder,  or  receptacle  of  the  urine,  is  a  mem- 
branous bag  compofed  of  different  coats,  one  of  which 
is  evidently  mufcular,  with  its  fibres  running  in  differ- 
ent direftions.  The  human  bladder  is  of  an  irregular 
oblong  figure.  The  fuperior  part  of  it  has  common- 
ly been  termed  its  fundus,  or  bottom :  the  oppofite 
extremity,  lying  at  the  bottom  of  the  pelvis,  is  termed 
the  cervix  or  neck ;  and  the  intermediate  fpace,  its 
middle  or  body.  The  bladder  is  every  where  nearly, 
though  not  exadly,  of  the  fame  diameter,  except  at 
its  fundus,  where  it  is  fomewhat  contracted  ;  and  again 
near  to  its  neck,  where  it  dilates  confiderably,  extend- 
ing back  towards  the  coccyx. 

The  fuperior  part  of  the  bladder  is  covered  with  the 
peritonaeum  ;  and  it  therefore  lies,  along  with  the  oth- 
er abdominal  vifcera,  within  the  abdominal  cavity ; 
but  the  under  part  of  it  is  not  covered  with  that  mem- 
brane. The  anterior  under  part  of  the  bladder  is  con- 
nected by  cellular  fubflance  to  the  pubes ;  laterally, 
it  is  fixed  by  productions  of  its  external  covering  to 
the  other  bones  of  the  pelvis  ;  and  pofteriorly,  it  is  in 
male  fubjeCts  firmly  connected  with  the  rectum,  from 


3e<a.  II.  Of  the  ^one.  tsf 

the  entrance  of  that  gut  into  the  pelvis,  till  within  a 
little  of  its  terminarion  in  the  anus,  when  the  neck  of 
the  bladder  and  commencement  of  the  urethra  fepa- 
rate  a  little  from  the  gut,  leaving  a  fpace  that  is  filled 
with  fat  and  cellular  fubftance. 

In  females,  the  uterus,  in  an  unimpregnated  ftate^ 
lies  altogether  in  the  cavity  of  the  pelvis,  immediately 
behind  the  bladder  ;  and  the  vagina,  in  which  the  os 
tincEe  terminates,  lies  diredly  behind  the  urethra,  and 
before  or  upon  the  inteflinum  redlum,  to  which  it  is 
firmly  attached. 

The  neck  of  the  bladder  terminates  in  the  com- 
mencement of  a  cylindrical  membranous  canal,  the 
urethra,  which  comes  off  at  nearly  a  right  angle  from 
the  anterior  part  of  it.  The  urethra,  at  its  commence- 
ment, is  furrounded  by  the  proflate,  a  gland  of  a  flat 
pyramidal  fliape,  with  its  bafe  towards  the  bladder, 
and  its  apex  pointing  to  the  perinazum ;  its  fuperior 
lamella  being  conneded  with  the  pubes,  and  its  infe- 
rior part  \^^th  the  anterior  and  under  part  of  the  rec- 
tum. 

The  urethra  continues  to  be  efitircly  membranous 
for  a  jQiort  fpace  after  it  leaves  the  apex  of  the  proflate 
gland  ;  and  this  part  of  it  keeps  in  clofe  contatt  with 
the  offa  pubis,  till  it  paffes  out  from  below  the  arch 
formed  by  thefe  bones,  which  it  does,  by  making  a 
curve  in  its  progrefs  to  the  perineum.  This  curva- 
ture in  the  urethra  it  is  material  to  be  well  acquaint- 
ed with,  particularly  in  the  operation  of  founding.  A 
good  anatomift  will  in  genei"al  pafs  a  ftaff  with  eafe, 
while  thofe  not  verfant  in  the  anatomy  of  the  parts 
concerned,  are  not  only  apt  to  fail  entirely,  but  are 
fure  to  give  much  unnecclfary  pain. 

The  commencement  of  the  urethra,  that  I  have  jufl 
defcribed,  is  termed  the  membranous  part  of  it ;  which, 
before  it  has  proceeded  an  inch  from  the  extremity  of 
the  proflate  gland,  is  furrounded  by  a  cellular  kind 
ot  body,  termed  the  corpus  fpongiofum  urethras,  which 
here  forms  a  kind  of  protuberance,  termed  the  bulb 


158  Of  ihe  Stone.  Chap.  XXlX. 

of  the  urethra  ;  and  which  afterwards  proceeds  along 
in  a  more  diffufed  ftate  to  the  extremity  of  the  penis, 
where,  by  expanding  again,  it  terminates  in  the  for- 
mation of  the  glans  penis. 

The  reft  of  the  penis  is  formed  of  the  preputium, 
which,  as  I  have  already  had  occafion  to  obferve,  is 
merely  a  doubling  of  the  fkin  ;  and  of  two  round  cav- 
ernous bodies,  termed  the  corpora  cavernofa  penis, 
which  originate  by  two  crura  or  legs  from  part  of  the 
OS  ifchium  and  pofterior  part  of  the  pubes  on  each 
fide  ;  and  having  united  near  the  fymphyfis  pubis, 
they  thus  form  the  principal  part  of  the  body  of  the 
penis,  and  are  continued  to  the  glans,  with  which  they 
are  connected,  but  with  which  the  cellular  or  caver- 
nous parts  of  thefe  bodies  have  no  direct  communica- 
tion. 

By  the  jun6lion  of  the  two  cavernous  parts  of  the 
penis,  which  are  nearly  round,  a  kind  of  hollow  is 
formed  both  above  and  below.  In  the  former  of  thefe, 
or  in  that  vacuity  which  runs  along  the  back  part  of 
the  penis,  the  principal  veins  of  the  penis  run  ;  and 
the  urethra  is  protected  by  the  latter.  The  obvious 
ufe  of  the  urethra  is  to  ferve  as  a  paflage  for  the  urine 
and  femen ;  the  receptacle  of  the  former  I  have  al- 
ready defcribed,  and  I  fhall  now  mention  thofe  of  the 
latter.  The  femen,  after  being  fecreted  by  the  teftes, 
is  by  two  very  fmall  tubes,  termed  vafa  deferentia, 
lodged  in  the  veficul^e  feminales,  which  are  found  to 
be  two  cellular  kinds  of  canals,  contorted  in  fuch  a 
manner  as  when  diftended  to  refemble  the  inteftines 
of  a  fmall  fowl.  They  are  feated  on  the  pofterior  part 
of  the  neck  of  the  bladder,  below  the  entrance  of  the 
ureters,  and  lie  in  clofe  contact  with  the  redluni ;  and 
the  femen  is  again  difcharged  from  thefe  receptacles 
by  two  excretory  dufts,  which  terminate  in  two  points, 
at  a  part  which,  from  its  figure,  has  been  termed  the 
caput  gallinaginis,  fituated  on  the  inferior  fide  of  the 
urethra,  nearly  about  the  middle  of  the  proftate  gland  ; 
and  a  little  below  the  entrance  of  thefe  canals  from  the 


Seel.  IL  Of  the  Stone.  159 

veficulae   feminales,  the  two  excretory  du£ts  of  the 
proflate  gland  empty  themfelves  into  the  urethra. 

The  niufcles  that  are  cut  in  the  lateral  operation  of 
lithotomy,  now  commonly  praftifed,  are  the  eredores 
penis,  acceleratores  urince,  tranfverfales  perinasi,  and 
levator  ani.  The  ereclor  penis  arifes  fi'om  the  tube- 
rofity  of  the  ifchium  ;  and,  after  covering  almofl  com- 
pletely the  crus  penis  of  the  fame  fide,  it  is  inferted 
by  a  tendinous  expanfion  into  the  fuperior  part  of  the 
penis,  near  to  where  it  joins  with  its  fellow  of  the  op- 
pofite  fide. 

The  accelerator  urinse  arifes  by  flefhy  fibres  from 
the  fphinder  ani  and  contiguous  foft  parts  ;  and  after 
covering  the  membranous  part  of  the  urethra,  it  is  in- 
ferted into  the  middle  of  the  bulb,  where  it  joins  with 
a  fimilar  mufcle  of  the  oppofite  fide :  part  of  thefe 
mufcles,  too,  run  along  the  crura  penis,  and  are  after- 
wards loft  ill  the  ligamentous  covering  of  the  corpora 
cavernofa.  The  tranfverfales  perina:i  are  two  thin 
narrow  mufcles,  which  originate  from  the  firm  mem- 
branous covering  of  the  tuberofity  of  the  ifchium, 
and,  after  ftretching  direclly  inwards,  are  inferted  into 
the  bulb  of  the  urethra. 

Befides  thefe  mufcles,  which  all  fuffer  more  or  lefs 
in  the  lateral  operation  of  lithotomy,  the  levator  ani 
mufl:  neceffarily  be  cut  in  the  fame  operation  ;  and  in 
the  high  operation  for  the  flone,  part  6f  the  mufculus 
tranfverfalis  abdominis,  of  the  redlus,  and  pyramidalis, 
are  alfo  cut. 

Almoft  all  thefe  parts  are  furnifhed  with  blood  by 
branches  from  the  internal  iliac  arterv  ;  and  thofe  vef- 
fels  which  run  mod  hazard  of  being  cut  in  the  lateral 
operation  for  the  (tone,  are,  the  arteria  pudica  interna, 
and  the  pudica  externa ;  for,  the  former  fupplies  not 
only  the  parts  about  the  anus,  but  the  bulb  of  the 
urethra  and  the  corpora  cavernofa ;  and  the  latter,  to 
wit,  the  pudica  externa,  fupplies  a  great  part  of  the 
bladder,  the  proflate  gland,  and  veficulcc  feminales. 


i6o  Of  the  Stone.  Chap.  XXIX. 

Having  thus  premlfed  all  that  Is  neceflary  for  our 
purpofe,  of  the  anatomy  of  thefe  parts,  I  fliall  now 
proceed  to  the  operation  of  founding. 

For  the  purpofe  of  difcharging  water  collected  in 
the  bladder,  a  curved  filver  tube  is  made  ufe  of,  nam- 
ed a  catheter,  different  forms  of  which  arc  delineated 
in  Plates  LXXI.  and  LXXII.  But  for  the  difcovery 
of  a  (lone  in  the  bladder,  a  folid  inflrument  made  of 
fleel  is  preferable,  as  the  fenfation  communicated  by  a 
firm  fubflance  is  more  diflincl  than  when  an  inftru- 
ment  of  filver,  or  any  other  fofter  material,  is  employ- 
ed. In  females,  the  urethra  runs  almoft  in  a  ftraight 
line  ;  fo  that  an  inflrument,  either  perfectly  ftraight, 
or  nearly  fo,  fuch  as  is  reprefented  in  Plate  LXXI.  fig. 
3.  is  more  eafily  introduced  than  one  with  a  large 
curvature :  but  in  male  fubjects,  the  turn  made  by 
the  urethra,  when  it  pafles  up  between  the  redum  and 
pubes,  is  fo  confiderable  as  to  preclude  entirely  the 
introdudion  of  a  ftraight  inftrument,  unlefs  much  vi- 
olence is  ufed.  By  preferving  the  penis  at  an  acute 
angle  with  the  body,  the  courfe  of  the  urethra  may 
indeed  be  rendered  fo  ftraight,  that  a  ftraight  probe 
may  be  eafily  introduced,  till  it  reaches  this  turn  to- 
wards the  farther  extremity  of  the  perinasum  ;  but  the 
curvature  made  by  the  urethra  at  this  place,  renders 
it  necelfary  to  employ  an  inftrument  with  a  corre- 
fponding  degr«r£  of  convexity. 

The  curvatures  commonly  given  to  thefe  inftru- 
ments  are  either  too  great  or  not  confiderable  enough. 
Either  extreme  renders  it  difficult  to  obtain  a  paflage 
into  the  bladder :  for  when  the  ftaft'  is  made  with  toa 
'much  convexity,  befides  being  more  difficult  to  intro- 
duce, it  gives  much  unnecefiary  pain,  by  ftretching 
and  even  tearing  the  urethra;  nof  can  an  inftrument"  *^: 
with  much  convexity,  be  fo  eafily  managed,  when  in  ■ 
the  bladder,  as  when  the  curvature  given  to  it  is  lefs.   * 
In  Plate  LXIX.  founds  are  reprefented   of   various 
fizes,  and  with  fuch  degrees  of  curvature,  as  by  expe-- 
rience  I  have  found  to  anfwer  bettej  than  any  other. 


Sea.  II.  Of  the  Stone,  l5i 

They  are  taken  from  the  natural  curvature  of  the 
urethra,  the  inflruments  from  whence  they  are  deline- 
ated having  been  exadly  adapted  to  that  paffage,  after 
the  furrounding  parts  were  removed. 

The  patient  to  be  founded  (liould  be  laid  upon  a 
bed,  with  his  head  raifed  on  a  pillow,  and  his  thighs 
fo  me  what  elevated  and  fcparated  from  each  other,  in 
which  pofition  the  mufcles  of  the  abdomen  are  put  in 
a  (late  of  relaxation.  The  furgeon,  if  he  employs  his 
right  hand  to  pafs  the  ftaff,  fliould  (land  on  the  left 
fide  of  the  patient,  and  the  found  fliould  be  of  a  fize 
proportioned  to  the  paffage  intended  to  receive  it. 
Having  previoufly  brought  it  to  the  heat  of  the  pa- 
tient's body  by  immerfion  in  warm  water,  and  having 
dipped  it  in  fine  oil,  he  is  now  to  grafp  the  penis  with 
his  left  hand  ;  and,  having  introduced  the  end  of  the 
found  into  the  urethra,  with  its  concave  fide  towards 
the  abdomen  of  the  patient,  he  mufl  pulh  it  eafily  on 
with  his  right  hand,  while  he  continues  with  his  left 
to  draw  the  penis  gently  forward  upon  the  inftru- 
ment. 

The  found  beine;  in  this  manner  carried  a  fufiicient 
length,  it  will  commonly  flip  eafily  into  the  bladder  ; 
but,  occafionally,  we  meet  with  difficulty  in  pafTmg  it 
tlirough  that  part  of  the  urethra  that  is  furrounded  by 
the  proflate  gland,  the  inflrument  being  apt  to  flop 
when  it  comes  to  this  part  of  the  paffage ;  and  here  I 
mufl  remark,  that  any  force  employed  for  pufhing  it 
further,  fhould  be  applied  with  much  caution.  That 
part  of  the  urethra  immediately  anterior  to  the  prpf- 
tate  gland  being  entirely  membranous  and  unfup- 
ported,  if  the  I'ound  at  this  part  meets  with  obflruc- 
tion,  and  if  flill  puflicd  forward  with  much  force, 
much  mifchief  mufl  neceflarily  enfue.  In  this  man- 
ner the  point  of  the  inftrument  is  often  forced  entire- 
ly through  the  urethra ;  by  which,  inflead  of  getting 
into  the  bladder,  it  forms  an  artificial  paffage,  either 
between  the  bladder  and  pubes,  or  between  the  blad- 

VoL.  III.  M 


1 62  Of  the  Stone,  Chap.  XXIX. 

der  and  rectum ;  an  occurrence  that  always  excites 
fevere  diftrefs  ;  and  which,  there  is  reafon  to  fear,  is, 
either  from  ignorance  or  inattention,  much  more  fre- 
quent than  it  ought  to  be. 

In  order  to  guard  againil  the  dreadful  confequences 
that  refult  from  this,  as  foon  as  it  is  found  that  the 
inflrument  does  not  pafs  eafily  along,  the  forefinger 
of  the  left  hand,  being  dipped  in  oil,  fnould  be  intro- 
duced into  the  redum,  when,  by  ftretching  the  parts 
and  elevating  the  point  of  the  ftaff,  while  at  the  fame 
time  the  inflrument  is  pufhed  gently  forward,  we 
commonly  procure  an  eafy  entrance  into  the  bladder. 
By  depreiling  the  handle  of  the  found,  we  alfo  elevate 
the  point  of  it,  and  in  this  manner  its  entrance  into 
the  bladder  is  fometimes  accomplifhed  ;  but  in  gene- 
ral the  introduction  of  the  finger  into  the  rectum  an- 
fwers  the  purpofe. 

Sounding  is  undoubtedly  a  very  nice  operation  ; 
and  dexterity  in  performing  it  can  only  be  acquired 
by  much  practice.  Every  fludent,  therefore,  ought 
to  embrace  all  opportunities  of  praftifmg  it,  firft  on 
the  dead  fubjeft,  and  afterwards  on  the  living  ;  for 
every  candid  practitioner  mufl  acknowledge,  that  he 
has,  in  different  inflances,  found  the  introduction  of  a 
catheter,  or  of  a  found,  both  difficult  and  uncertain  : 
but  when  the  parts  concerned  are  not  inflamed,  fwel- 
led  or  ulcerated,  the  operation  does  not  often  mifgive 
in  the  hands  of  an  expert  furgeon. 

The  ftaff  being  introduced,  the  operator  (hould  lay 
hold  of  the  handle  Avith  one  hand  ;  and  if  any  part  of 
it  comes  in  contact  with  the  flone,  the  bufmefs  of 
founding  is  accomplifhed ;  and  we  are  thus  rendered 
certain  of  the  nature  of  the  difeafe :  but  if  the  flone 
is  not  foon  difcovered,  it  may  commonly  be  found  by 
moving  the  inflrument,  fo  as  to  make  its  point  pafs 
eafily  from  one  fide  of  the  bladder  to  the  other. 
When  the  flone,  hov/ever,  is  fmall,  and  has  fallen  in- 
to that  part  of  the  bladder  that  lies  below  the  entrance 
of  the  urethra,  the  flafF  is  apt  to  pafs  over  it.     With 


1 


Sea.  II.  Of  the  Stone.  i6^ 

a  view  to  obviate  this  difficulty,  the  finger  of  the  left 
hand  may  be  again  introduced  into  the  redlum,  fo  as 
to  elevate  that  part  of  the  bladder  in  which  the  flone 
lies  concealed.  If,  again,  even  this  attempt  fliould 
fail,  the  patient's  body  fliould  be  put  into  a  different 
pofiure ;  and  no  fituation  will,  in  general,  anfwer  fo 
well  as  lowering  the  head  and  upper  part  of  the  body, 
while,  at  the  fame  time,  we  raife  the  pelvis.  In  this 
manner  a  ftone,  if  not  contained  in  a  particular  cyft, 
which  it  rarely  is,  may  be  moved  from  the  projedlion 
at  the  neck  of  the  bladder  towards  its  fundus,  where  it 
will  be  more  readily  llruck  with  the  found.  But 
when,  even  by  this  pofture  of  the  body,  we  do  not 
fucceed,  every  variety  of  pofition  ought  to  be  tried : 
the  patient's  head  may  be  elevated,  and  the  pelvis  de- 
prefl'ed ;  he  may  be  made  to  ftand  ered  ;  or,  what  I 
have  fometimes  known  to  fucceed  after  other  attempts 
had  failed,  he  may  be  made  to  fland  upon  his  feet, 
with  his  body  bending  forward. 

It  fometimes,  however,  happens,  when  the  ftone  is 
fmall,  and  the  capacity  of  the  bladder  large,  that  our 
firfl  attempt  in  founding  fails  entirely  ;  but  when  the 
fymptoms  of  flone  are  ftrongly  marked,  and  whea 
fchirrofity  and  ulceration  of  the  parts,  which  might 
give  rife  to  thefe  fymptoms,  are  not  found  to  exift,  we 
ought  not  to  reft  fatisfied  with  one,  or  even  with  two 
trials.  I  have  known  a  Hone  difcovered  on  the  third 
or  fourth  founding,  which  had  efcaped  the  inflrument 
in  all  the  preceding  trials. 

When  a  flone  is  ftruck  with  the  ftaff,  the  fenfation 
it  communicates  to  the  operator  is  fo  peculiar,  as  to 
render  it  impoffible  for  any  to  be  deceived  in  it  by 
whom  it  has  ever  been  felt  ;  but  with  thofe  who 
have  not  been  accuflomed  to  this  operation,  a  harden- 
ed flate  of  the  bladder  communicates  fuch  a  fenfation 
through  the  flafF,  as  frequently  proves  the  caufe  of  de- 
ception. This  has  even  happened  with  pradirioners 
of  much  experience  and  obfervation  :  it  is  reported  of 

M  2 


1 64  Of  the  Stone.  Chap.  XXIX. 

the  moft  celebrated  lithotomift  of  this,  or  perhaps  any 
other  country,  that,  in  the  courfe  of  his  pratlice,  which 
indeed  was  very  extenfivc,  three  patients  were  cut  by 
him  in  whom  no  flones  were  difcovered,  and  where  a 
fchirrous  or  hardened  ftate  of  the  bladder  had  given 
rife  to  the  miftake.*  With  praditioners  of  experi- 
ence, however,  this  can  never  happen  but  from  inat- 
tention ;  for  I  will  venture  to  affirm,  that  a  perfon  ac- 
cuflomed  to  the  fenfation  communicated  by  a  ftone, 
can  never,  if  he  attends  to  what  he  is  doing,  be  de- 
ceived by  the  application  of  the  found  to  a  fchirrous 
or  any  other  tumor. 

There  being  the  lead  hazard,  however,  of  fuch  a 
misfortune  as  the  one  I  have  mentioned,  namely,  that 
of  a  patient  being  made  to  undergo  all  the  pain  and 
rifk  of  the  operation  of  lithotomy,  when  no  flone  has 
exifled,  is  a  point  of  fuch  a  ferious  nature,  and  fraught 
with  fuch  confequences,  both  to  the  patient,  praftition- 
er,  and  art  of  furgery,  as  ought  to  excite  the  moll  ac- 
curate attention  to  this  part  of  the  operation. 


SECTION    III. 
General  Remarks  on  the  Operation  of  Lithotomy, 

THE  prefence  of  a  ftone  in  the  bladder  being  af- 
certained  in  the  manner  I  have  mentioned,  the 
means  to  be  employed  for  the  relief  of  the  patient,  is 
the  next  objedt  of  confideration. 

The  public  have  at  different  periods  been  amufed 
with  encomiums  on  the  Hthontriptic  powers  of  differ- 
ent articles,  particularly  of  lime  water,  and  of  eauftic 
alkali  in  a  diluted  ftate,  and  more  lately  of  aerated  al- 
kaline water ;  but  although  fome  human  calculi  are 
foluble  in  all  of  thefe  liquids,  yet  none  of  them  can 

•'  The  late  Mr.  Clicfclden. 


Sea.  III.  Of  the  Stone,  165 

be  conveyed  In  fuch  a  ftate  to  the  bladder  as  to  be 
much  depended  on.  Many  indeed  have  obtained  re- 
lief from  the  ufe  of  thefe  remedies :  the  pain  has,  by 
their  means,  been  rendered  Icfs  fevere,  and  the  pa- 
roxyfms  lefs  frequent ;  but  we  have  not  one  authenti- 
cated inflance  of  a  (tone  in  the  bladder  being  diffolv- 
ed  by  the  ufe  of  thefe,  or  any  other  remedy. 

As  the  conftituent  principles  of  thefe  and  other  II- 
thontriptic  medicines,  render  them  liable  to  very  ma- 
terial changes  in  their  circulation  from  the  flomach 
to  the  bladder,  it  has  been  propofed  to  convey  them 
directly  into  the  bladder  itfelf,  in  order  to  bring  them 
into  immediate  contact  with  the  ftone ;  and  machines 
have,  accordingly,  been  invented  for  the  purpofe  :  but, 
after  a  great  many  trials  have  been  made  with  reme- 
dies of  this  clafs,  it  feems  now  to  be  admitted,  that  no 
folvent,  powerful  enough  to  have  any  effect  upon  a 
ftone,  can  be  injefted  into  the  bladder,  but  with  the 
greateft  hazard  of  injuring  that  organ.  But  as  fome 
pradlitioners  Hill  continue  to  think  favourably  of  it,  I 
have  given  a  delineation,  in  Plate  LXXIV.  fig.  1.  of 
a  machine  by  which  liquids  may  with  eafe  be  thrown 
into  the  bladder.  Every  attempt,  however,  of  this 
kind  is  now  in  general  laid  afide  ;  and  as  no  depend- 
ence is  to  be  placed  upon  the  lithontriptic  powers  of 
any  medicine  taken  by  the  mouth,  the  only  refource  we 
have  is,  the  removal  of  the  ftone  by  a  chirurgical  ope- 
ration. In  this  manner,  if  his  conftitution  is  found, 
the  patient  may  again  enjoy  as  good  health  as  he  did 
before  he  was  attacked  with  the  difeafe ;  and  unlefs 
the  operation  is  performed,  the  remainder  of  a  mife- 
rable  life  will  probably  be  cut  ftiort  by  the  frequent 
returns  of  pain  and  fever,  to  which  people  in  this  fitu- 
ation  are  conftantly  liable. 

We  ought,  however,  to  remember,  that  although  a 
great  proportion  of  thofe  who  are  cut  for  the  ftone 
recover  and  do  well,  yet  a  confiderable  degree  of  dan- 
ger  always  attends  the  operation ;  fo  that,  before  ad- 
vifing  any  perfon  to  fubmit  to  it,  fuch  circumftances 


i66  Of  the  Stone.  Chap.  XXIX. 

ought  to  be  confidered  with  attention,  as  can  beft  en- 
able us  to  form  a  juH:  prognofis  of  the  event. 

By  experience  it  is  found,  that  children  more  rea- 
dily recover  from  this  operation  than  adults  ;  and  it 
is  likewife  obferved,  that  old  people,  from  the  fifty- 
fifth  to  the  feventieth  year,  whofe  conflitutions  are  not 
impaired,  run  lefs  rifk  from  it  than  men  in  the  full 
vigour  of  life.  This  may  poffibly  arife  irom  the  in- 
flammatory fymptoms  which  ufually  fucceed  to  this 
operation,  being  more  apt  to  proceed  to  a  dangerous 
height  in  young  plethoric  people  than  in  older  pa- 
tients ;  and  we  know  from  experience  that  more  dan- 
ger is  to  be  dreaded  from  inflammation  after  this  ope- 
ration than  from  any  other  caufe.  But  at  whatever 
period  of  life  the  patient  is,  if  he  is  otherwife  healthy, 
more  fuccefs  is  to  be  expedted,  than  if  his  conftitution 
had  been  previoufly  impaired  by  frequent  returns  of 
the  difeafe  ;  efpecially  when  it  has  continued  fo  long 
as  to  produce  ulceration  in  any  part  of  the  bladder. 

In  an  ulcerated  ftate  of  the  bladder,  if  the  patient  is 
advanced  in  years,  he  could  not  expert  much  enjoy- 
ment of  life,  even  although  he  were  to  recover  from 
the  operation  :  in  this  fituation,  therefore,  a  prudent 
practitioner  would  rather  decline  to  operate  :  inflead 
of  it,  he  would  rather  advife  a  plentiful  ufe  of  mucil- 
aginous drinks  ;  an  occafional  ufe  of  the  warm  bath  ; 
together  with  dofes  of  opiates  proportioned  to  the  de- 
gree of  pain.  By  thefe  means  the  violence  of  the 
pain  is  fometimes  mitigated,  and  the  patient  is  there- 
by faved  from  the  diftrefs  of  a  fevere  operation,  the 
effedls  of  which,  in  a  conftitution  fuch  as  I  have  men- 
tioned, frequently  prove  fatal. 

But  even  in  thefe  circumftances,  if  the  patient  is 
young,  if  he  is  fuffering  much  from  the  difeafe,  and 
if  not  fo  weak  as  to  render  it  probable  that  the  quan- 
tity of  blood  ufually  loft  in  the  operation  may  irre- 
parably injure  his  health ;  I  would  decidedly  advife 
the  operation.  His  chance  of  recovery  will,  undoubt- 
edly, be  lefs  than  if  his  health  had  otherwife  been  un-  ^ 


I 


Sea.  III.  Of  the  Stone.  167 

impaired  ;  but,  if  he  is  lucky  enou<:^h  to  furvive  the 
operation,  he  may  enjoy  life  with  comfort  and  eafe. 

The  operation  being  refolved  on,  the  next  point  to 
be  determined  is  the  befl  method  of  doing  it.  From 
the  anatomical  defcription  that  I  have  given  of  the 
parts  with  which  the  human  bladder  is  furrounded,  it 
appears,  that  there  are  only  two  points  at  which  it  can 
with  propriety  be  laid  open.  A  confiderable  part  of 
the  fundus  of  the  bladder  I  have  fhown  to  be  covered 
with  the  peritonaeum  ;  fo  that  to  open  it  here,  would 
be  attended  with  imminent  danger,  from  the  certainty 
of  expofmg  the  abdominal  vifcera,  not  only  to  the  ef- 
fects of  the  atmofphcre,  but  to  the  irritation  of  the 
urine,  on  finding  accefs  to  the  cavity  of  the  peritonae- 
um by  the  wound  in  the  bladder.  The  poflerior  part 
of  the  bladder  I  have  fliewn  to  be  either  immediately 
.  covered  with  bone,  or  internally  connecled  with  parts 
which  it  would  be  highly  improper  to  injure ;  and 
thefe  particularly  are,  the  redum ;  the  veficulce  femi- 
nales ;  and  the  vafa  deferentia  and  ureters. 

The  only  parts  of  the  bladder,  therefore,  which  can 
with  a  chance  of  fafety  be  cut  into,  are,  that  portion 
of  the  anterior  part  of  it,  lying  immediately  below  the 
peritonreum,  and  which,  when  in  a  ftate  of  diflention, 
is  raifed  fomewhat  above  the  pubes ;  where  an  inci- 
fion  direclly  above  the  brim  of  the  pelvis  will  lay  that 
part  of  it  bare  where  it  is  not  covered  with  the  perito- 
naeum, and  where,  accordingly,  an  opening  into  it 
may  be  made :  and,  again,  that  portion  of  the  blad- 
der that  we  term  its  neck,  which  may  be  opened  lat- 
erally by  an  incifion  in  the  perinceum,  without  any 
danger  of  wounding  other  parts  of  importance. 

It  is  in  one  or  other  of  thefe  parts  that  any  opening 
into  the  bladder  can  be  made  with  fafety.  Some  prac- 
titioners, indeed,  have  attempted  to  cut  into  it  at  the 
poflerior  part  of  its  neck,  or  even  into  the  body  of  it 
at  once  ;  but  the  hazard  of  wounding  parts  of  much 
importance  is  here  fo  great,  that  for  this  and  other 
reafons  to  be  mentioned  hereafter,  every  operation  of 


t6S  Of  the  Stone,  Chap.  XXIX, 

this  kind  is  now  laid  afide.  We  fliall  prefently,  how- 
ever, enter  more  fully  into  the  difcullion  of  this  point, 
by  giving  a  detail  of  the  various  means  that  have  been 
propofed,  from  the  time  of  Celfus  downwards,  for  the 
purpofe  of  extrading  flones  from  the  bladder ;  and 
this  I  Ihall  do  in  the  order  of  time  that  thefe  opera-t 
tions  were  introduced  into  pradtice. 

The  diftrefs  and  mifery  that  urinary  calculi  excite, 
were  probably  experienced  in  the  earliefl;  ages  of  the 
world.  Relief,  we  may  therefore  fuppofe,  would  be 
fought  for,  by  the  removal  of  the  ftones,  as  foon  as 
fuch  a  knowledge  of  anatomy  was  obtained  as  could 
juflify  the  attempt.  We  find  accordingly,  from  the 
writings  of  Hippocrates,  that  even  at  this  early  period, 
the  operation  for  the  ftone  was  frequently  performed  ; 
but  as  it  was  then  folely  praftifed  by  a  particular  fet 
of  men  termed  lithotomifts,  we  have  received  no  ac- 
count from  this  author  of  their  method  of  doing  it. 
Celfus  is  the  firfl  who  defcribes  the  method  of  oper- 
ating at  the  time  when  he  lived ;  and  it  was  done  by 
making  an  opening  in  the  body  of  the  bladder,  direft? 
ly  upon  the  (lone  itfelf.  From  the  fmall  number  of 
xnftruments  ufed  in  this  method  of  cutting,  it  has  been 
termed  the  operation  by  the  leffer  apparatus. 


SECTION.     IV. 

Of  the  Operation  of  Lithotomy  by  the  LeJJer  Apparatus. 

THE  perfon  to  be  cut  being  properly  fecured,  (the 
ealieft  and  beft  method  of  effeding  which,  I 
fhall  defcribe  in  Section  VII.)  the  furgeon  muff  dip 
the  fore  and  middle  fingers  of  his  left  hand  in  oil ;  and 
having  introduced  them  into  the  redum  of  the  patient, 
he  is  to  fearch  for  the  (lone,  and  pufh  it  forward  to- 
wards the  perinosum,  fo  that  it  may  be  felt  between 
the  fcrotum  and  anus.     In  order  to  facilitate  this  part 


Sea.  IV.  Of  the  Stone,  169 

of  the  operation,  and  to  get  the  ftone  properly  fixed, 
either  the  furgeon  or  an  afliftant  fhould  prefs  with  his 
right  hand  upon  the  under  part  of  the  abdomen,  at 
the  fame  time  that  the  furgeon  himfelf  is  pufhing  the 
ftone  forward  with  his  fingers  in  the  reftum,  in  which 
manner  it  is  to  be  preffed  forward  below  the  pubes, 
and  fecured  on  one  fide  of  the  perinseum,  between 
thefe  bones  and  the  anus.  This  being  done,  we  are 
direfted  by  Celfus  to  make  a  femilunar  cut  through 
the  fkin,  cellular  fubflance,  and  mufcles  ;  beginning 
on  one  fide  of  the  anus,  and  carrying  the  cut  direftly 
over  the  centre  of  the  tumor  formed  by  the  projetlloii 
of  the  ftone.  The  bladder  being  thus  laid  bare,  a 
tranfverfe  inclfion  is  made  through  the  coats  of  it  di- 
redlly  upon  the  ftone  ;  when  the  ftone,  if  it  is  fmall, 
may  probably  be  turned  out  by  preflure  from  behind 
with  the  fingers  in  the  rtftum  ;  but  if  it  is  large,  and 
does  not  come  away  eafily,  we  are  defired  by  Celfus 
to  take  the  affiftance  of  a  hook  for  fcooping  it  out. 

This  operation,  with  a  few  variations,  continued,  fo 
far  as  we  know,  to  be  the  only  method  of  cutting  for 
the  ftone,  till  the  beginning  of  the  fifteenth  century, 
when  another  method  of  operating,  to  be  hereafter 
defcribed,  was  propofed,  and  very  generally  adopted. 
Long  after  this  period,  however,  this  operation  of  Cel- 
fus was  ftill  continued  by  many  ;  and  the  eafe  with 
which  it  is  accompliftied,  not  only  from  the  fmall  num- 
ber of  inftruments  with  which  it  is  done,  but  from  lit- 
tle or  no  anatomical  knowledge  being  requlfite,  pre- 
ferved  it  in  conftant  ufe  with  itinerants,  who  continu- 
ed, even  to  a  late  period,  to  praftife  it  in  different  parts 
of  Europe,  under  the  name  of  the  operation  upon  the 
gripe.^ 

This  method  of  cutting  for  the  ftone  is  Indeed  fo 
eafily  performed,  particularly  in  early  infancy,  that, 
even  in  thefe  times,  many  of  our  well  informed  prac- 
titioners have  a  ftrong  partiality  towards  it.  At  fo 
late  a  period  as  the  time  of  Heifter,  we  find  it  was 
much  in  repute,  infomuch  that  Heifter  himfelf  per- 


170  Of  the  Stone,  Chap.  XXIX. 

formed  it  frequently  ;  but  a  wrong  reprefentatlon  has 
commonly  been  given  of  the  parts  that  are  cut  in  it ; 
for  it  has  been  commonly  fuppofed,  that  by  cutting  di- 
rectly upon  the  ftone,  the  bladder  itfelf  muft  alone  be 
wounded,  while  all  the  neighbouring  parts  of  impor- 
tance arc  imagined  to  efcape  unhurt ;  a  circumftance 
that  would  recommend  it  Ilrongly,  if,  on  experience, 
it  was  found  to  be  the  cafe.  This,  however,  is  far 
from  being  fo ;  as  all  who  will  make  the  experiment, 
will  readily  perceive. 

A  flrict  attention  to  the  anatomy  of  the  parts,  might 
at  once  indeed  convince  us  of  the  difficulty,  if  not  of  the 
abfolutc  impoffibiUty,  of  cutting  from  the  perinasum  di- 
rectly upon  a  ftone  in  the  bladder,  without  deftroying 
either  the  vafa  deferentia,  veficulye  feminales,  or  ex- 
cretory duels  of  thole  receptacles  ;  the  deftru£lion  of 
which  would  produce  the  ufual  effects  of  caftration 
with  as  much  certainty  as  a  total  extirpation  of  the 
teftes  themfelves.  Thefe  parts  are  all  placed  upon 
the  under  and  back  part  of  the  bladder  ;  and  as  they, 
as  well  as  the  ureters,  are  immediately  connefted  with 
that  part  of  the  bladder  that  is  cut  in  this  operation, 
it  is  perhaps  impoliible  to  perform  it  without  dividing 
one  or  all  of  them. 

As  I  had  once  a  favourable  opinion  of  this  opera- 
tion, I  thought  that  in  fome  inftances  it  might  be  ufe- 
fully  employed,  if,  on  experience,  it  fhould  appear  that 
thefe  parts  could  be  avoided  with  the  fcalpel.  I  ac- 
cordingly put  it  frequently  in  practice  on  dead  fub- 
jects  ;  but  although  in  all  of  them  it  was  done  with 
every  pofTible  attention,  it  was  conftantly  found  either 
that  the  veficuiae  feminales  were  divided,  or  that  their 
excretory  ducts  were  cut  acrofs.  This,  however,  was 
not  all ;  for  although  in  fome  inftances  the  urethra 
was  not  touched,  yet  in  others  it  was  found  to  be  com- 
pletely laid  open  before  the  fcalpel  reached  the  blad- 
der. In  every  inftance  where  the  operation  is  perform- 
ed in  the  manner  directed  by  Celfus,  the  urethra  muft 
neceflarily  be  cut,  before  the  inftrument  reaches  the 


Sea.  IV.  Of  the  Stone.  171 

bladder.  For  it  is  altogether  impofTible  to  make  a 
tranfverfe  incifion  into  the  bladder,  in  the  manner  ad- 
vifed  by  Celfus,  without  previoufly  palling  through 
part  of  the  urethra  ;  the  fartheft  extremity  of  that  ca- 
nal being  always  puflied  forward  by  the  fingers  in  the 
rectum,  in  fuch  a  manner  as  to  render  it  impollible  to 
avoid  it  in  this  method  of  performing  the  operation. 

But  in  mod  of  the  trials  that  I  made  upon  dead 
fubjects,  for  this  purpofe,  I  attempted  what  I  confider 
as  a  material  improvement  of  Celfus's  method.  A 
tranfverfe  or  femilunar  incifion  through  the  teguments 
and  mufcles,  I  believe  to  be  better  adapted  than  any 
other,  for  giving  a  free  paflage  to  the  (tone ;  but  as 
the  bladder  is  compofed  of  a  very  dilatable  membra- 
nous fubllance,  there  is  no  neceflity  for  a  tranfverfe 
cut  being  made  in  it.  After  laying  the  bladder  bare, 
therefore,  by  a  femicircular  cut  along  the  courfe  of 
the  flone,  inflead  of  continuing  the  fame  kind  of  in- 
cifion with  which  the  operation  commenced,  a  longi- 
tudinal cut  was  made  directly  on  the  centre  of  the 
ilone,  in  order  to  avoid  with  as  much  certainty  as  pof- 
fiblc  all  thofe  parts  that  fliould  not  be  injured.  Even 
with  this  precaution,  however,  although  the  urethra 
was  avoided,  fome  of  the  other  parts  I  have  mention- 
ed were  always  divided  ;  fo  that  although  they  may 
by  accident,  perhaps,  be  avoided  once  in  a  great  num- 
ber of  times,  I  am  confident  that  even  the  mofl:  expert 
anatomid  would  feldom  be  able  to  make  an  opening 
into  this  part  of  the  bladder,  fufficient  for  extrading  a 
flone  of  a  moderate  fize,  without  dividing  either  the 
veficulse  feminales,  the  vafa  deferentia,  or  their  excre- 
tory du£ls.  In  fome  infi:ances,  too,  the  entrance  of 
the  ureters  into  the  bladder  is  fo  low  down,  as  to  ren- 
der them  liable  to  be  cut  in  this  operation.  This,  how- 
ever, is  a  rare  occurrence  ;  but  it  has  in  fome  inftan- 
ces  happened. 

Another  important  objedion  to  this  operation  is, 
that  the  bladder  being  pufhed  forward,  and  divided  at 
a  part  that  mufl  afterwards  recede  from  the  wound  iii 


1/3  Of  the  Stone,  Chap.  XXIX. 

the  teguments,  much  rifk  mud  be  Incurred  of  the  for- 
mation of  fmufes,  by  the  urine  infmuatlng  into  the 
neighbouring  parts ;  and  we  have  to  add  to  this,  that 
in  general  this  operation  mufl  be  confined  to  the  early- 
periods  of  infancy.  The  readings  of  Celfus  with  which 
we  are  furniihed,  limit  the  performance  of  this  opera- 
tion to  the  age  of  ten,  or  from  that  to  the  fourteenth 
year ;  but  this  mufl  furely  be  confidered  as  an  error 
in  the  late  editions  of  that  work,  as  this  mode  of  op- 
erating is  unqueftionably  better  adapted  for  the  earlieft 
periods  of  infancy,  than  for  the  more  advanced  flages 
of  it,  infomuch  that  it  may  always  be  done  with  more 
or  lefs  eafe,  in  proportion  to  the  thicknefs  of  parts 
about  the  rectum  and  bladder ;  and  this,  again,  de- 
pends in  a  great  meafure  on  the  age  of  the  patient. 
"We  are  told,  indeed,  of  fome  practitioners  who  per- 
formed this  operation  on  people  of  every  age,  of  eve- 
ry habit  of  body,  and  whether  corpulent  or  not.  Such 
accounts,  however,  have  never  appeared  to  be  au- 
thentic. 

Among  other  improvements  of  this  operation  of 
Celfus,  the  ufe  of  forceps  for  extracting  the  ftone,  was 
perhaps  the  greatefl ;  but  neither  this,  nor  any  other 
advantage  it  can  receive,  can  obviate  the  difficulties 
I  have  mentioned.  We  find  accordingly,  that,  about 
the  beginning  of  the  1 6th  century,  fome  time  between 
the  year  1500  and  1520,  a  new  method  of  operating 
for  the  ftone  was  propofed  at  Rome,  by  Johannes  de 
Romanis,  as  we  are  afterwards  informed  by  one  of 
his  pupils,  Marianus,  and  whofe  name  has  been  com- 
monly given  to  it  ;  this  being  termed  the  methodus 
mariana,  or  lithotomy  by  the  greater  apparatus,  from 
the  great  number  of  iliftruments  that  at  firft  were  em- 
ployed in  it. 


K^' 


Sea.  V.  OftheSione,  173 

SECTION     V. 

Of  Liihoiomy  by  the  Greater  Apparatus, 

BY  this  operation  a  palTage  is  made  into  the  blad- 
der, by  cutting  into  the  urethra  at  the  bulb ;  at 
which  a  variety  of  inftruments  were  introduced,  for 
the  purpofe  of  dilating  the  paffagc  to  fuch  a  fize  as 
might  eafily  admit  of  the  extratlion  of  the  ftone. 

For  a  confiderable  time  after  this  operation  was 
propofed,  a  number  of  inventions  were  brought  forth, 
for  the  fole  purpofe  of  rendering  the  dilatation  of  the 
urethra  and  adjacent  parts  more  eafy.  Thefe  it  is 
unnecefTary  to  enumerate,  as  an  account  of  the  ope- 
ration, as  it  was  lafl  pratlifed  in  its  mofl  improved 
ftate,  will  ferve  to  communicate  all  that  is  neceffary 
to  be  known  concerning  it. 

The  patient  being  fecurcd,  and  placed  upon  a  table 
in  the  manner  to  be  defcribed  more  particularly  in 
Sedion  VII.  a  grooved  ftafl'  was  then  paffed  through 
the  urethra  into  the  bladder ;  the  handle  of  the  in- 
ftrument  being  carried  over  the  right  groin,  while  its 
convex  part  was  made  to  pufli  out  the  urethra  on 
the  left  fide  of  the  perinceum.  In  this  pofition  the 
ftaff  v/as  prefer  ved  by  an  alTiflant,  who  like  wife  fuf- 
pendcd  the  fcrotum  ;  while  the  operator,  with  a  fcal- 
pel  in  his  right  hand,  made  an  incifion  from  the  very 
bottom  of  the  fcrotum  to  within  a  (inciter's  breadth  of 
the  anus,  carrying  it  along  the  left  fide  of  the  peri- 
nicum,  within  a  very  little  of  the  rapha. 

The  ikin,  cellular  fubftance,  and  mufcles,  being  thus 
divided,  the  urethra  itfelf  was  now  opened  in  its  bulb, 
by  cutting  direftly  into  the  groove  of  the  ftaff ;  and 
the  incifion  was  completed  by  carrying  the  knife  along 
to  the  extremity  of  the  urethra,  at  the  commencement 
of  the  proftate  gland. 

Various  indruments  were  at  one  period  in  ufe, 
termed  dilators,  and  male  and  female  ccndudors,  for 


1/4  Of  the  Stone.  Chap,  XXIX. 

the  purpofe  of  finlfliing  the  operation,  by  dilating  fuch 
parts  as  were  not  cut ;  and  the  timidity  of  fome  ope- 
rators  was  fuch,  that  they  dilated,  Itretched,  or  lace- 
rated almoft  all  that  part  of  the  urethra  that  lies  be- 
tween the  bulb  and  proflate  gland  ;  a  degree  of  cau- 
tion by  no  means  ncceffary,  and  which,  by  the  vio- 
lence which  this  dilatation  did  to  the  parts,  was  fure 
to  produce  very  diflrefsful  confequences.  Other  prac- 
titioners, however,  performing  the  operation  fo  far  in 
the  fame  manner,  hnifhed  the  other  parts  of  it  in  a 
different  way.  They  liril  introduced  a  blunt  gorget 
into  the  bladder,  by  running  its  beak  along  the  groove 
of  the  flaff,  and  puihing  it  forward,  fo  as  to  force  a 
paffage  through  the  proilate  gland  ;  and  this  being 
done,  the  forefinger  of  the  left  hand  was  pufhed  along 
the  gorget,  and  with  it  the  paffage  was  further  dilat-j^. 
ed,  till  the  opening  was  fuppoied  to  be  fufficiently 
large  for  the  ftone  to  pafs  through  it. 

The  opening  into  the  bladder  being  in  this  manner 
completed,  the  flone  was  extracted  in  the  manner  I 
fhall  hereafter  point  out,  when  treating  of  the  lateral 
operation.,  in  Section  VII.  by  the  ufe  of  different  for- 
ceps adapted  to  the  fize  of  the  parts  ;  and  on  extract- 
ing the  ftone,  all  thofe  parts  that  were  not  cut  in  the 
previous  fteps  of  the  operation,  were  of  necellity  great- 
ly lacerated. 

Although  this  operation  was  long  practifed,  it  is  li- 
able to  many  objections.  Of  thefe,  the  number  of 
inftruments  ufed  in  it  is  mentioned  as  one :  but,  in 
the  improved  ftate  of  the  operation,  that  I  have  de- 
fcribed,  this  objection  is  entirely  removed,  no  more 
inftruments  being  ufed  in  it  than  are  daily  employed 
in  the  molt  fimple  method  of  performing  the  lateral 
operation  ;  namely,  a  fcalpel,  a  gorget,  and  forceps 
for  extracting  the  ftone.  But  the  material  objections 
to  which  it  is  liable  are,  that  by  beginning  the  inci- 
fion  too  near  to  the  fcrotum,  much  more  of  the  ure- 
thra is  cut  than  is  neceffary :  by  not  dividing  the 
proftate  gland  with  the  fcalpel,  the  parts  are  fo  much. 


Sea.  V.    •  Of  the  Stone.  175 

lacerated,  firll  by  the  forcible  introdu6l:ion  of  the 
blunt  gorget,  and  then  by  the  extraftion  of  the  ftone, 
as  muft  be  the  caufe  of  much  irreparable  mifchief : 
and  laflly,  by  the  parts  not  being  freely  divided,  we 
might  frequently  find  it  impofiible  to  extract  large 
{tones  by  this  operation,  which,  in  the  lateral  method 
now  praOifed,  might  pafs  with  eafe.  In  other  re- 
fpedts,  however,  this  operation  poflefied  much  merit, 
and  it  required  only  to  be  improved  in  a  few  circuni- 
ftances,  to  become  the  real  lateral  operation  of  mod- 
ern practitioners .  Thefe,  however,  it  is  unnecellary 
to  enlarge  upon  here,  as  they  will  be  afterwards  par- 
ticularly pointed  out  in  the  defcription  to  be  given  of 
the  lateral  operation. 

After  this  operation  had  been  practifed  for  thirty 
or  forty  years,  fome  of  the  inconveniencies  that  refult 
from  it  fuggeiled  the  idea  of  what  was  afterwards  term- 
ed the  high  operation ;  an  appellation  which  it  deriv- 
ed from  the  bladder  being  cut  into  above  the  ofla 
pubis. 

About  the  year  1561,  Franco,  a  French  fiirgcon  of 
this  name,  publifhed  a  treatife  on  hernias  ;*  and  here 
•we  find  the  firfl:  account  of  the  high  operation.  It 
was  firfl  fuggefled  to  Franco  by  accident ;  for  hav- 
ing, as  he  informs  us,  met  with  a  large  ftone  in  a  child 
two  years  of  age,  which  he  could  not  polTibly  extradt 
by  the  operation  then  practifed  in  the  perinseum,  he 
was  induced  to  open  the  bladder  above  the  pubes  : 
but  although  the  ftone  was  extracted,  and  the  child 
recovered.  Franco  never  performed  the  operation 
again  ;  and  he  even  advifes  it  not  to  be  done  by  oth- 
ers, from  the  great  danger  which  he  thinks  will  at- 
tend it. 

The  next  account  we  find  of  it  is  by  Roffet,  in  a 
publication  on  this  and  other  fubjects,  publifhed  at 
Paris  in  the  year  1590.  But  it  does  not  appear  that 
he  ever  performed  the  operation  himfelf ;  nor  was  it 

*  Traitc  tres  ample  des  Hcrnies,  par  Pierre  Franco. 


iy6  Of  the  Stone.  Chap.  XXtX.- 

any  where  much  pradifed  till  fome  time  after  the 
commencement  of  the  prefent  century,  when  it  was 
adopted  and  keenly  patronifed  in  London  by  Mr. 
Chefelden  and  Mr.  Douglas. 

During  the  twelve  or  fifteen  years  immediately  fub- 
fequent  to  the  year  1720,  the  high  operation  was  fre- 
quently performed  both  in  London,  Edinburgh,  and 
other  parts  of  Europe  ;  but  the  lateral  operation,  with 
the  improvements  upon  it  by  Rau,  being  then  more 
generally  known,  the  fuperior  advantages  it  was  found 
to  poffefs  very  quickly  procured  it  a  preference  ;  and 
fince  this  period  the  high  operation  has  never  been 
generally  praftifed,  either  in  this  or  any  other  coun- 
try ;  but  I  fhall  now  proceed  to  defcribe  the  method 
of  doins:  it. 


t) 


SECTION     VI. 

Of  the  High  Operation  for  the  Stone, 

I  HAVE  already  made  it  appear,  that  the  fundus  of 
the  bladder,  or  that  part  of  it  lying  highefl  in  the 
{Delvis,  is  covered  with  the  peritoneum  ;  fo  that  at 
this  part  no  opening,  it  is  evident,  can  be  made  in  it 
with  fafety,  as  the  operator  would  not  only  incur  the 
rifk  of  wounding  the  inteftines,  but  the  urine  would 
be  apt  to  efcape  into  the  abdomen.  It  is  the  anterior 
part  of  the  bladder,  namely,  that  part  of  it  that  lies 
between  the  middle  of  it  and  its  neck,  that  ought  to 
be  opened  in  this  operation  :  but  this  part  of  the  blad- 
der is  feldom  fufficiently  elevated,  and  as  one  com- 
mon efFeft  of  the  ftone  in  the  bladder  is  to  induce  a 
diminifhed  or  contracted  ftate  of  it,  this  circumftance 
of  itfelf  is  a  very  important  objeftion  to  this  opera- 
tion ;  for  unlefs  the  bladder  can  contain  a  large  quan- 
tity, at  leaft  a  pound  and  a  half  in  an  adult,  it  ought 
not  to  be  attempted. 


Sed.  VI.  Of  the  Stone,  177 

Various  methods  have  been  propofed  for  diftending 
the  bladder.  Some  ha\'^  faid  that  it  may  be  done  by 
throwing  air  into  it  with  bellows ;  and  others  have 
advifed  a  quantity  of  wa'er  to  be  injected  immediately 
before  the  operation,  and  to  retain  it  by  forming  a 
ligature  on  the  penis.  Both  of  thefe  methods,  how- 
ever, are  apt  to  do  harm  by  diftending  the  bladder 
too  fuddenly  ;  and  we  are  even  told  by  fome,  that  it 
has  been  burft  by  this  kind  of  treatment.  Means, 
therefore,  of  a  more  harmlefs  nature  fhould  be  at- 
tempted ;  and  it  may  be  done  without  running  any 
riflv  of  hurting  the  bladder,  merely  by  the  patient  be- 
ing accudomed,  for  a  confiderable  time  before  the 
operation,  to  retain  his  urine  as  long  as  poffible  ;  and 
as  foon  as  it  is  found  that  he  can  retain  a  fufficient 
quantity,  by  paffing  a  ligature  upon  the  penis  ten  or 
twelve  hours  before  the  operation,  and  caufing  him  to 
drink  plentifully  of  any  diluent  drink,  we  may  be  al- 
moft  certain  of  producing  an  eafy  and  fufficient  de- 
gree of  diftention. 

This  being  done,  the  patient  muft  be  laid  upon  a 
firm  table,  about  three  feet  four  inches  in  height ;  at 
the  fame  time  that  his  legs  and  arms  fhould  be  fecur- 
ed,  not  with  ligatures,  but  with  the  hands  of  aflift- 
ants.  In  order  to  guard  as  much  as  poffible  againfl 
any  injury  being  done  to  the  bowels,  the  patient  fhould 
be  laid  with  his  head  confiderably  lower  than  his  bo- 
dy, and  his  thighs  and  buttocks  raifed.  By  this  fitu- 
ation,  too,  the  ftone,  which  would  othersvife  fall  into 
the  neck  of  the  bladder,  where  it  could  not  be  very 
accefhble,  is  brought  more  contiguous  to  the  intend- 
ed opening,  and  is  thereby  more  eafily  laid  hold  of, 
either  with  forceps  or  the  fingers. 

The  patient  being  thus  properly  fecured,  an  incifion 
is  to  be  made  with  a  round  edged  fcalpel,  diredly 
upon  one  fide  of  the  linea  alba,  beginning  about  four 
inches  above  the  offa  pubis,  and  ending  at  the  fym- 
phyfis  of  thefe  bones :  even  the  linea  alba  itfelf  may 
Vol.  III.  N 


178  Of  the  Sme.  Chap.  XXIX. 

be  cut  with  fafety ;  but  is  is  better  to  avoid  it,  as  the 
incifion  is  more  eafily  made  in  foft  parts  than  in  ten- 
dons or  ligaments.  The  Ikin  and  cellular  fubftance 
being  freely  divided,  the  redti  and  pyramidales  muf- 
cles  come  fuccefiivcly  into  view :  in  general,  the  in- 
cifion may  be  carried  on  merely  by  feparating  thefe 
mufcles  from  one  another ;  but  no  harm  could  be 
done  by  fome  of  their  fibres  being  cut. 

A  fufficient  opening  of  the  exlernal  parts  being  in 
this  manner  obtained,  the  operator  fiiould  now  fearch 
with  his  fingers  for  the  bladder,  which  he  will  com- 
monly difcover  immediately  above  the  pubes.  With 
the  fingers  of  his  left  hand  he  fiiould  now  prefs  back 
the  peritonaeum,  with  the  inteflines  contained  in  it, 
and  with  the  fame  fcalpel  with  which  he  performed 
the  preceding  fleps  of  the  operation,  he  fliould  pene- 
trate the  bladder  itfelf  in  its  moft  prominent  part. 
This  opening  into  the  bladder  fhould  at  once  be  made 
fo  large  as  to  admit  two  of  the  fingers  of  the  opera- 
tor's left  hand  ;  which  being  introduced,  the  incifion 
fhould  be  enlarged  to  the  length  of  three  inches,  by 
running  a  probe  pointed  biftoury  along  one  of  the 
fingers,  down  towards  one  fide  of  the  neck  of  the 
bladder.  The  inflant  that  the  fingers  are  introduced 
into  the  bladder,  the  ligature  upon  the  penis  fliould 
be  taken  off,  fo  that  the  water  contained  in  it  may  be 
difcharged  by  the  urethra,  otherwife  the  whole  will  be 
difcharged  by  the  wound,  and  part  of  it  might  lodge 
among  the  contiguous  mufcles. 

The  incifion  being  in  this  manner  completed,  the 
operator  ought  to  fearch  with  his  fingers  for  the  ftone, 
and  if  poffible,  it  fhould  be  extracted  without  the  af- 
fiftance  of  inftruments :  but  if  this  does  not  fucceed, 
forceps  mufl,  no  doubt,  be  employed.  One  great  ad- 
vantage tlKit  we  derive  from  this  operation  is,  that  as 
the  extraftion  of  the  flone  does  not  require  much 
force,  fo  it  is  here  rarely  known  to  break :  but  when 
this  misfortune  takes  place,  the  pieces  will  be  more 
eafily  removed  with  the  fingers  alone,  than  with  any 


Sed.  VI.  Of  the  Stone.  179 

of  the  fcoops  commonly  employed.  The  ftones  be- 
ing removed,  the  upper  part  of  the  wound  in  the  teg- 
uments fhould  be  drawn  together,  either  with  ftrong 
adhefive  plafters,  or  with  the  twifted  future,  care  be- 
ing taken  to  leave  at  lead  an  inch  and  a  half  in  the 
under  part  of  it  open,  in  order  to  difcharge  any  urine 
that  may  be  thrown  out  from  the  wound  in  the  blad- 
der into  the  contiguous  parts.  It  might  even  be  prop- 
er to  keep  the  whole  external  incilion  open  till  the 
wound  in  the  bladder  is  reunited ;  but  as  the  bowels, 
fupported  now  by  the  peritonjeum  only,  would  be  apt 
to  protrude  at  this  opening,  and  as  this  would  prove 
not  only  troublefome  but  highly  dangerous,  it  ought 
by  all  means  to  be  guarded  againft. 

With  this  view,  the  bowels  fliould  be  kept  open 
with  gentle  laxatives,  and  the  patient  during  the  whole 
courfe  of  the  cure  fhould  be  kept  with  his  head  and 
upper  part  of  the  body  low,  and  the  pelvis  elevated. 

The  parts  injured  in  this  operation  are  not  any 
where  nearly  furrounded  with  bone ;  fo  that  large 
flones  can  be  extrafted  with  more  eafe  in  this  than  in 
any  other  way  :  and  as  the  wound  in  the  bladder  is 
made  far  from  its  neck,  fiftulous  openings  are  not  fo 
apt  to  enfue  from  it  as  from  incifions  in  the  perina^um. 
Thefe  are  two  advantages  that  we  derive  from  this 
operation  ;  but  the  objeftions  to  it  are  various. 

I.  When  the  bladder  does  not  admit  of  fuch  dif- 
tention  as  to  be  raifed  above  the  pubes,  it  is  almoft 
impolTible  to  make  an  opening  into  it  without  divid- 
ing the  peritonaeum.  From  this  much  danger  would 
undoubtedly  enfue  ;  air  would  find  accefs  to  the  whole 
furface  of  the  alimentary  canal ;  the  bowels  would 
protrude,  and  urine  would  efcape  into  the  cavity  of 
the  abdomen. 

Many,  indeed,  affert,  that  no  danger  enfues  from 
the  protrufion  of  the  bowels  ;  that  the  wound  heals 
with  the  fame  eafe,  and  that  the  patients  recover  equal- 
ly well  as  if  this  did  not  happen.     No  pradition- 

N  2 


i8o  Of  the  Stone.  Chap.  XXIX, 

er,  however,  In  thefe  times,  will  give  credit  to  this, 
and  it  is  accordingly  a  very  important  objcftion  to  the 
high  operation. 

2.  As  the  urine  is  apt  to  find  accefs  between  the 
peritongeum  and  abdominal  mufcles,  as  well  as  be- 
tween the  bladder  and  pubes,  troublefome  fmufes  are 
apt  to  form  in  the  cellular  fubftance  of  thefe  parts,  and 
as  no  vent  can  be  made  for  the  matter,  they  always 
terminate  in  much  diftrefs. 

3.  It  has  been  obferved,  when  the  habit  of  body  is 
not  entirely  good,  that  a  cure  cannot  be  obtained  eith- 
er of  the  wound  in  the  bladder,  or  external  teguments. 
This,  it  will  be  faid,  may  be  alleged  as  an  objedfon 
to  every  important  operation ;  but  it  has  been  com- 
pletely efhabliflied  by  obfervation,  that  degrees  of  dif- 
eafe  in  the  conftitution  prove  highly  detrimental  in  the 
high  operation  for  the  itone,  which  in  the  ufual  meth- 
od of  operating  in  the  perina;um  give  much  lefs  caufe 
of  alarm. 

4.  This  operation  is  confined  almoft  entirely  to  pa- 
tients under  thirty  years  of  age :  for  although  it  was 
at  one  period  frequently  pradifed  on  older  people,  and 
although  no  particular  reafon  can  be  given  why  it 
ought  not  to  fucceed  in  more  advanced  ages,  yet  we 
learn  from  almoft  every  author  who  has  written  upon 
it,  particularly  from  Middleton,  Smith,  Douglas,  and 
Heifter,  that  a  very  fmall  proportion  only  recover  of 
fuch  as  have  pafled  their  thirtieth  year. 

It  is  perhaps  for  one  or  other  of  thefe  reafons  that 
the  high  operation  has  fallen  into  difufe,  and  that  it 
has  not  been  much  praftifed  for  a  great  length  of  time 
in  almoll  any  part  of  Europe.  But  although  this 
method  of  operating  is  attended  with  hazard,  and  is 
frequently  followed  with  diftrefsful  confequences,  yet 
there  is  reafon  to  think,  that,  in  particular  circum- 
ftances,  it  might  be  pra6:ifed  with  advantage. 

The  mofl  material  objection,  to  the  modern  or  lat- 
eral method  of  performing  this  operation,  arifes  from 
the  bruifing  of  the  foft  parts  againfl  the  contiguous 


f 


i 


Sea.  VI.  Of  the  Stone.  i  S  i 

bones  in  the  extraftion  of  a  large  ftone  ;  which  is  fo 
much  the  cafe,  that  we  may  confider  the  rilk  in  that 
operation  to  be  almoft  in  proportion  to  the  fize  of  the 
ftone.  When  a  ftone  is  fmall  and  eafily  extraded, 
the  proportion  of  deaths  in  the  lateral  operation  is  ve- 
ry fmall :  but  whenever  the  ftone  is  of  fuch  a  fize  as 
to  weigh  feven,  eight  or  ten  ounces,  it  is  perhaps  one 
of  the  mofh  dangerous  operations  to  which  a  patient 
can  fubniit.  In  different  inftances,  too,  the  ftone  has 
been  fo  large,  that  it  could  not  be  taken  out  by  the 
lateral  operation ;  nay,  fome  cafes  are  on  record,  in 
which  it  became  necelfary  to  perform  the  high  opera- 
tion, after  the  operator  had  failed  in  extrading  the 
ftone  by  the  ufual  method  of  cutting  in  the  peri- 
naeum.* 

When,  therefore,  from  the  long  continuance  of  the 
difeafe ;  from  the  fenfe  of  weight  about  the  neck  of 
the  bladder  ;  and  particularly  when  from  the  touch  by 
the  finger  in  ano,  we  have  reafon  to  fufpe«5t  the  ftone 
to  be  large,  it  ought  to  be  an  objecl  of  confideration, 
how  far  it  may  be  proper  to  avoid  the  lateral,  and  in 
certain  circumftances,  to  employ  the  high  operation. 
The  circumftances  to  which  I  allude,  rcfpecl  the  age 
of  the  patient,  the  foundnefs  of  his  conftitution,  and 
the  poilibility  of  diftending  the  bladder  fo  as  to  raife 
it  above  the  brim  of  the  pelvis.  Thefe  circumftances 
are  favourable  where  the  ftone  is  large  ;  and  v.  hen  it 
is  known  to  be  fo,  the  high  operation,  although  lefs 
advantageous  in  the  general  run  of  calculous  cafes 
than  the  lateral  method  of  cutting,  may  be  praclifed 
with  a  greater  probability  of  fuccefs  than  any  other 
with  which  we  are  acquainted. 

Having  now  faid  all  that  is  neceflary  refpeding  the 
apparatus  altus,  we  ftiall  proceed  to  the  conftderailon 
of  what  has  ufually  been  termed  the  lateral  operation. 

*  We  find  that  it  happened  to  Htifter.  Vide  Heifter's  Surgery,  p.  a. 
Sea.  V.  Chap.  CXLII. 


i8a  Of  the  Stone,  Chap.  XXIX, 

SECTION    VII. 

Of  the  Lateral  Operation, 

IN  the  operation  of  lithotomy,  as  it  was  formerly 
praclifed  by  the  great  apparatus,  the  external  in- 
cifion  was  made  in  nearly  the  fame  part  that  it  is  now 
in  the  lateral  operation  ;  but  the  two  methods  of  ope- 
rating are  materially  different  in  every  other  circum- 
ftance. 

The  original  invention  of  the  lateral  operation  is 
due  to  a  French  ecclefiaftic,  commonly  known  by  the 
name  of  Frere  Jacques.  This  operator  firfl:  appeared 
at  Paris  in  the  year  1697,  when,  by  the  fuccefsful 
event  of  a  few  cafes,  he  vvas  defnxd  to  operate  upon 
a  great  number.  But  it  foon  appeared  to  practition- 
ers of  difcernment,  that  the  fame  he  had  acquired 
would  not  probably  be  of  long  duration.  For  with  a 
very  imperfe6t  knowledge  of  the  anatomy  of  the  parts 
concerned  in  the  operation,  a  bad  afforlment  of  inflru- 
ments,  and  a  total  negledt  of  his  patients  after  the 
operation,  it  was  fcarcely  poffible  that  much  fuccefs 
could  refult  from  his  method.  His  manner  of  operat- 
ing was  as  follows : 

The  patient  being  properly  fecured,  either  upon  a 
table  or  on  a  bed,  a  common  folid  ftaff  was  introduc- 
ed into  the  bladder  by  the  urethra,  and  the  handle 
being  carried  over  the  right  groin,  the  convex  part  of 
it  was  made  to  elevate  the  teguments  and  other  parts 
on  the  left  fide  of  the  perinseum. 

With  a  flraight  biftoury  he  now  made  an  incifion 
through  the  fkin  and  cellular  fubftance,  beginning  be- 
tween the  anos  and  tuberofity  of  the  ifchium,  and 
proceeded  upwards  along  the  left  fide  of  the  perinas- 
um,  at  a  fmall  diftance  from  the  rapha,  till  it  extend- 
ed at  leafl  one  half  of  the  courfe  of  the  perinseum. 
"With  the  fame  knife  he  now  went  on  along  the  direc- 


Sea.  VII.  Of  the  Stone.  183 

tion  of  the  ftaff,  to  divide  the  parts  between  the  exter* 
nal  incifion  and  the  bladder,  which  he  alio  opened 
with  the  point  of  the  fame  knife  with  which  the  other 
fteps  of  the  operation  had  been  done.  At  this  open- 
ing in  the  bladder  he  firfl  introduced  the  index  of  his 
left  hand,  in  order  to  difcover  the  fituation  of  the 
ftone  J  and  having  withdrawn  the  ftaff,  he  laid  hold 
of  the  ftone  with  forceps,  and  performed  the  extrac- 
tion in  the  ufual  manner.  The  patient  was  now  car- 
ried to  bed,  and  no  farther  attention  was  paid  to  him 
by  the  operator,  who  never  applied  any  dreftings,  as 
he  trufted  the  fubfcquent  management  of  every  cafe 
to  the  nurfe  or  other  attendants. 

In  confeqiience  of  this  unpardonable  negle6l,  and 
by  frequently  cutting  parts  in  the  courfe  of  the  opera- 
tion which  he  ought  to  have  avoided,  a  great  propor- 
tion of  thofe  on  whom  he  operated  died  ;  no  lefs,  we 
are  informed,  than  twenty-five  of  fixty.*  Hence  Jac- 
ques foon  fell  into  difrepute ;  and  although  he  after- 
wards made  many  improvements  in  his  method  of 
operating,  particularly  in  ufmg  a  grooved  ftaff  inftead 
of  a  folid  one,  and  in  being  more  attentive  to  the  fub- 
fequent  management  of  his  patients,  yet  his  reputation 
in  Paris  never  gained  ground ;  nor  do  we  find  that 
his  method  was  ever  attended  with  much  fuccefs,  eith- 
er in  Holland,  or  in  the  various  parts  of  Germany, 
where  he  afterwards  praclifed. 

For  with  fo  much  inattention  did  he  proceed,  that 
although  he  profefTed  to  cut  direftly  into  the  body  of 
the  bladder,  without  injuring  either  the  urethra  or 
proftate  gland  ;  yet  in  the  dilfeclion  of  fuch  bodies  as 
died  of  the  operation,  it  was  found,  that  in  many  th« 
proftate  gland  was  divided,  together  with  the  veficu- 
las  feminales.  In  fome  inftances,  the  bladder  was  cut 
in  two  or  three  different  parts  ;  in  others  the  redlum 
was  divided ;  and  it  even  frequently  happened,  that 

'*  Vide  Morand  Opufcules  de  Chirurgic,  partie  li.  p.  5  4« 


1 84  Of  the  Stone.  Chap.  XXIX. 

the  bladder  was  entirely  feparated  from  the  urethra.* 
We  need  not  wonder,  therefore,  that  this  practition- 
er, as  well  as  his  method  of  operating,  foon  fell  into 
difcredit.  Biit  although  this  was  a  confequence  that 
necefTarily  enfued  from  the  ill  fuccefs  that  atteneded  his 
praftice  ;  yet  the  world,  we  nuifl  admit,  is  much  in- 
debted to  Jacques,  for  having  laid  the  foundation  of 
the  lateral  method  of  cutting  for  the  Hone,  which,  in 
its  prefent  improvtd  ftate,  is  practifed  with  fo  much 
fuccefs  over  all  Europe. 

Rau  was  the  firll  who  endeavoured  to  improve  this 
operation  of  Frere  Jacques,  which  he  did  by  ufmg  a 
ftafF  with  a  deep  groove,  by  which  he  was  enabled  to 
continue  the  incifion  into  the  bladder  with  more  cer- 
tainty than  can  be  done  with  a  fhaft'  entirely  folid.  But 
Rau,  afraid  of  wounding  the  proilate  gland,  introduc- 
ed a  refinement  into  his  method  of  cutting,  which,  in 
the  event,  proved  extremely  hurtful,  and  was  proba; 
bly  the  caufe  of  its  being  aftervv'ards  laid  afide.  For, 
inftead  of  dividing  the  urethra  and  proftate  gland,  by 
which  the  extradion  of  the  flone  would  have  been 
made  eafy,  he  difl'eded  with  much  caution  by  the  fide 
of  the  proftate,  till  the  convex  extremity  of  the  ftafF 
was  difcovered  in  the  bladder  itfelf.  At  this  part  an 
incifion  was  made  into  it,  and  the  ftone  thereafter  ex- 
traded,  in  the  manner  then  praclifed  for  cutdng  with 
the  great  apparatus. 

By  this  method  of  operating,  the  redum  and  vefi- 
culas  feminales  were  in  great  danger  of  being  injured  ; 
the  ftone  was  extraded  with  difficulty  ;  and  from  the 
depth  of  the  incifion,  the  urine  did  not  pafs  eafily  off 
by  the  wound,  fo  that  troublefome  fmufes  frequently 
enfued.  t 

*  For  a  particular  account  of  Frcre  Jacques's  method  of  operating,  fee 
Dr.  Lifter's  Journey  to  Paris ;  the  works  of  Dionis,  Mcri,  Collet,  Saviard, 
and  Morand. 

f  Rau  himfclf  kept  this  method  of  operating  as  much  concealed  as  pofi 
fible.  But  an  account  of  it  was  publidicd  after  his  death,  by  Albinus  ; 
who,  by  aiCflJng  frequently  at  his  operations,  became  perfecfUy  mafter  of 
the  manner  of  performing  it.  Vide  Index  fiippcUctSlilis  anatomicae,  &c. 
JLug.  Batavorum. 


Se<a.  \1I.  Of  the  Stone.  1 85 

Thefe  inconveniencies  prevented  this  operation  of 

Rau  from  ever  being  generally  received,  and  fuggeft- 

ed  to  our  countryman,  the  celebrated  Chefelden,  the 

lateral  method  of  cutting  as  it  is  now,  with  a  few  al- 

.  terations,  very  univerfally  praftifed. 

As  this  operation  of  Mr.  Chefelden  is  defcribed  by 
many  writers  in  furgery,  it  is  not  here  neceflary  to  en- 
ter into  a  detail  of  it :  I  (hall  now,  therefore,  proceed 
to  defcribe  the  lateral  operation  in  its  prefent  improv- 
ed (late. 

I'hat  the  patient  may  not  find  it  neceflary  to  go 
foon  to  ftool  after  the  operation,  feveral  flools  fliould 
be  procured  by  a  purgative  on  the  preceding  day  ; 
and  with  a  view  to  difcharo-e  the  contents  of  the  rec- 
turn  more  entirely,  an  injection  fhould  be  given  a  few 
hours  before  the  operation  is  performed. 

When  the  bladder  is  in  a  collapfed  ftate,  it  is  liable 
in  this  operation  to  be  cut  in  different  parts  by  the 
gorget ;  the  patient  ought  therefore  to  be  defired  to 
drink  plentifully  of  fome  diluent  liquor,  and  to  retain 
his  urine  for  feveral  hours  before  being  laid  upon  the 
table  :  in  fome,  however,  the  irritation  produced  by 
the  difeafe  is  in  fuch  a  degree  as  entirely  to  prevent 
this  voluntary  retention  of  urine  ;  in  which  cafe  the 
penis  Ihould  be  fiightly  comprefTed  with  a  broad  fillet 
for  fome  hours  before  the  operation  ;  and  we  leflen 
or  remove  the  irritation  by  a  large  dofe  of  opium. 

Thefe  circumftances  being  adjufted,  and  the  perin- 
fEum  and  parts  about  the  anus  being  fliaved,  the  pa- 
tient is  now  to  be  laid  upon  a  table  for  the  operation. 
The  moft  convenient  height  for  this  table  is  three  feet 
two  inches.  It  ought  to  be  perfectly  firm  ;  and,  that 
there  may  be  fufficient  fpace  for  the  patient,  it  fhould 
be  about  three  feet  eight  inches  long,  and  two  feet  and 
a  half  wide. 

The  patient  fliould  be  completely  and  properly  fe- 
cured,  and  the  following  is  perhaps  the  befl  method 
of  domg  it :  let  a  noofe  be  formed  in  the  double  of  a 
piece  of  broad  firm  tape,  five  feet  in  length :  the  pa« 


1 86  Of  the  Stone.  Chap.  XXIX, 

tient's  wrlfts  being  paffed  through  this  noofe,  he  fliould 
be  defired  to  take  a  firm  hold  of  the  outfide  of  the  an- 
kle of  the  fame  fide,  when,  by  different  turns  of  the 
tape  round  the  hand,  ankle  and  foot,  his  hand  is  to  be 
firuily  fecured  in  this  polition  ;  and  this  being  done 
on  one  fide,  the  hand  and  foot  of  the  oppofite  fide  are 
to  be  firmly  tied  together  in  the  fame  manner. 

The  operator  fhould  now  introduce  a  grooved  flafF, 
of  a  fize  proportioned  to  the  parts  through  which  it  is 
to  pafs.  Different  fizes  of  thefe  ftaffs  are  reprefented 
in  Plate  LXIX  ;  the  artifl  who  makes  them  fliould 
round  off  the  edges  of  the  grooves,  otherwife  they  are 
apt  to  injure  the  urethra  ;  and  the  extremity  of  the 
groove  fhould  be  perfectly  free  and  open,  otherwife  it 
is  difficult  to  difengage  the  gorget  after  it  has  paffed 
into  the  bladder.  As  the  groove  is  only  neceffary  in 
the  convex  part  of  the  ftaff,  and  from  that  to  its  point, 
the  handle  of  the  inftrument,  down  to  the  commence- 
ment of  the  convexity,  fliould  be  entirely  folid,  fo  as 
to  admit  of  the  penis  being  preffed  upon  it  without  be- 
ing hurt,  either  by  the  hand  of  the  aflifl;ant,  or  by  a 
piece  of  tape,  which  may  be  fometimes  neceffary,  as  I 
have  already  advifed,  for  preventing  the  urine  from 
being  difcharged. 

I  may  here  remark,  that  more  attention  fliould  be 
given  to  the  length  of  the  fl:aff  than  is  commonly  done. 
Staffs  are  in  general  too  fliort  ;  fo  tliat  when,  in  the 
courfe  of  the  operation,  the  handle  is  preffed  down 
upon  the  groin  by  the  affiftant,  the  point  is  very  apt 
to  flip  entirely  out  of  the  bladder ;  a  circumfliance  to 
be  guarded  againfl;  with  all  poffible  attention,  and  it 
cannot  with  luch  certainty  be  done  as  by  making  the 
ftaff  always  of  a  fufficient  length. 

The  fl:one  being  again  diflinctly  felt,  not  only  by,; 
the  furgeon  himfelf,  but  by* his  aflifl:ants,  the  patient-^ 
muff  now  be  placed  in  that  pofture  in  which  he  is  to 
be  kept  during  the  remainder  of  the  operation.  ^The 
table  intended  to  be  ufed  fliould  be  perfectly  level ; 
but,  that  the  patient  may  lie  upon  it  with  as  much  eafe 


Sea.  VII.  Of  the  Stone.  187 

as  pofTible,  a  pillow  may  be  put  under  his  head,  and, 
that  the  pelvis  may  be  higher  than  the  abdomen,  there 
Ihould  be  at  lead  two  pillows  under  his  buttocks,  which 
fhould  be  made  to  projed  an  inch  or  two  over  the  end 
of  the  table. 

A  due  elevation  of  the  buttocks,  is  highly  important, 
although  feldom  attended  to  by  the  operator  ;  indeed, 
the  very  reverfe  is  often  advifed,  the  head  and  upper 
part  of  the  body  being  generally  kept  higher  than  the 
pelvis.  This,  however,  can  arife  from  inattention  on- 
ly ;  for  we  may  by  the  leafl  reflexion  be  convinced, 
that  the  more  eredl:  the  body  is  kept,  the  greater  will 
be  the  preffure  of  the  inteftines  upon  the  bladder  ;  and 
if,  by  this  preffure,  the  fundus  of  the  bladder  is  forced 
down  upon  its  neck,  the  rifk  of  its  being  wounded 
mull  be  great  indeed. 

Of  fuch  patients  as  have  died  of  this  operation,  I 
have,  in  different  inflances,  found  on  diffection,  that 
the  bladder  was  wounded  in  three  different  parts  :  in 
its  cervix,  as  is  always  the  cafe  when  the  gorget  is  of 
a  proper  length  ;  in  its  fide  confiderably  above  the 
cervix  ;  and,  again,  in  the  fundus  or  upper  part  of  it. 
Now,  this  can  never  happen,  if  the  diredions  I  have 
given  are  kept  in  view  ;  for  when  the  bowels  are  pre- 
vented from  falling  upon  the  bladder,  by  the  buttocks 
being  raifed  above  the  reft  of  the  body,  and  if,  at  the 
fame  time,  the  bladder  is  properly  diftended  with 
urine,  it  muft  be  altogether  impoffible,  in  the  ufual  lat- 
eral operation,  to  injure  it  in^an  improper  part.  But 
if  this  precaution  of  having  the  bladder  diftended  dur- 
ing the  operation  is  negleded,  at  the  fame  time  that 
the  bowels,  by  an  elevated  pofture  of  the  upper  part 
of  the  body,  are  allowed  to  fall  into  the  pelvis,  the 
bladder  muft  be  fo  completely  collapfed,  and  its  fun- 
dus puftied  fo  much  down  upon  its  neck,  as  muft  fre- 
quently be  the  caufe  of  much  unneceffary  hazard. 

Befides  the  cafes  to  which  I  allude,  in  which  the 
bladder  was  after  death  found  to  be  wounded  in  dif- 
ferent parts,  we  find  a  very  candid  acknowledgment 


i88  Of  the  Stone,  Chap.  XXIX. 

made  by  a  celebrated  lithotomift,  of  his  being  once  fo 
unfortunate  in  the  lateral  operation,  that  a  confidera- 
ble  portion  of  the  fmall  guts  pafTed  immediately  out  at 
the  wound.* 

This  would  certainly  have  difconcerted  many  oper- 
ators :  but,  fortunately  for  the  patient,  the  operation 
was  in  this  cafe  completely  finilhed  ;  the  bowels  were 
reduced  and  a  perfed  cure  was  obtained.  Mr.  Brom- 
field  endeavours  to  account  for  this  protrufion  of  the 
bowels  in  a  different  manner  ;  but  I  am  much  inclin- 
ed to  believe,  that  it  happened  from  the  pelvis  not 
having  been  fufficiently  raifed  above  the  reft  of  the 
body,  and  from  the  bladder  having  been  in  a  collapf- 
ed  ftate  at  the  time  the  incifion  was  made  in  it.  For 
this  author,  it  muft  be  remarked,  inftead  of  ordering 
the  bladder  to  be  diftcndcd  at  the  time  of  operating, 
defires  exprefsly  that  it  may  be  emptied  immediately 
before  the  operation.! 

Matters  being  adjufted  in  the  manner  I  have  advif- 
ed,  with  refped  to  the  patient,  an  aififtant  on  each  fide 
is  to  fecure  his  legs  and  arms  :  one  muft  prevent  him 
from  moving  the  upper  part  of  his  body  ;  another 
muft  lay  hold  of  the  ftaff ;  and  a  fifth  is  required  to 
hand  the  necefiary  inftruments  to  the  operator. 

The  furgeon,  after  having  again  felt  the  ftone  with 
the  ftaff,  is  now  to  make  the  hand  of  it  pafs  over  the 
right  groin  of  the  patient,  fo  that  the  convex  part  of 
it  may  be  diftinguifhed  on  the  left  fide  of  the  perinae- 
um  :  in  this  pofition  it  may  be  exa6Hy  preferved  by 
the  affiftant,  who  with  his  right  hand  ftiould  lay  hold 
of  the  handle  of  the  ftaff,  while  with  his  left  he  ele- 
vates and  fiipports  the  fcrotum. 

The  thighs  of  the  patient  being  fufficiently  feparat- 
ed  by  the  alliftants,  and  the  furgeon  being  feated  be- 
tween the  patient  and  the  window,  in  fuch  a  manner 
that  the  light  may  fall  diredly  upon  the  perinaeum, 

*  Vide  Mr.  Bromfield's  Chlrurgical  Obfervations  and  Cafes,  Volume  H. 
page  264. 
t  Page  aa8,  Vol.  II. 


Sea.  VII.  Of  the  Stone.  i8$ 

an  incifion  is  now  to  be  made  with  a  common  round 
edged  fcalpel  through  the  fkin  and  cellular  fubftance, 
at  leaft  four  inches  in  length  in  a  full  grown  perfon, 
and  fo  in  proportion  in  fmaller  fized  people  ;  begin- 
ning a  little  to  the  left  fide  of  the  rapha,  nearly  an  inch 
below  the  termination  of  the  fcrotum,  and  proceeding 
along  the  fame  fide  of  the  perinaeum,  till  it  runs  at  an 
equal  diftance  between  the  tuberofity  of  the  ifchiuni 
and  the  anus,  which  lafl  it  ought  to  pafs  at  lead  aa 
inch. 

As  the  fuccefs  of  the  operation  depends  in  a  great 
menfure  on  this  part  of  it  being  properly  performed, 
it  ought  at  all  times  to  be  done  with  the  utmoft  atten- 
tion. From  timidity  or  inattention,  this  external  in- 
cifion is  commonly  made  too  fhort :  inftead  of  four 
inches,  I  have  often  feen  it,  even  in  the  largeft  adult, 
fcarcely  two.  In  confequence  of  this,  the  mufcles,  and 
other  parts  below,  are  not  properly  divided  ;  the  op- 
erator has  not  freedom  to  profecute  the  other  fteps  of 
the  operation ;  and  if  the  ftone  is  large,  the  parts 
through  which  it  has  to  pafs  muft  be  much  more  bruif- 
ed  and  lacerated  than  if  they  had  been  freely  cut  with 
the  knife  ;  and  as  no  harm  can  enfue  from  the  exter- 
nal incifion  being  free  and  ample,  it  ought  in  every 
inllance  to  be  fo.  Much  hazard  may  enfue  from  the 
divifion  of  the  teguments  and  mufcles  being  fmall  j 
but  none  from  their  being  largely  laid  open. 

By  this  firft  ftroke  of  the  fcalpel,  the  fkin  and  cel- 
lular fubftance  (hould  be  freely  divided,  fo  as  to  bring 
the  fubjacent  mufcles  completely  in  view ;  when,  by 
a  continuation  of  the  incifion,  the  ereftor  penis,  accel- 
erator urinse,  tranfverfalis  perins^i  and  levator  ani 
fliould  be  cut.* 


•  Soon  after  *he  flrrt  edition  of  this  work  was  publiflied,  my  friend 
Dr.  Monro,  in  convcrfing  on  the  lateral  operation  of  litliotomv,  obfcrved, 
that  I  had  dclircd  mufcJes  to  be  cut  which  mi^ht  be  avoided ;  and  know- 
\ng  that  Sharpe,  Camper,  and  others  who  wrote  upon  this  operation,  footi 
after  that  important  improvcm<  nt  was  iniroducetl,  of  cutting  the  proflatc 
gland  with  the  K<^ro;et  of  Hawkins,  inflcad  of  the  fcalpel,  were  of  opinion, 
that  the  cxtcnfivc  divifion  that  I  have  advifcd  of  thefe  parts  was  uanecei- 


19©  Of  the  Stone,  Chap.  XXIX* 

As  no  danger  enfues  therefore  from  a  free  divifion 
of  thefe  parts,  and  as  a  large  opening  not  only  facili- 
tates the  extraction  of  the  Hone,  but  admits  of  any 
blood  veiTel  that  is  cut  being  eafily  fecured  with  a  lig- 
ature, which  can  never  be  done  when  the  incifion  is 
fmall,  it  ought  in  every  inflance  to  be  large.  In  gen- 
eral, the  arteries  with  which  thefe  mufcles  are  fuppli- 
ed  are  not  fo  large  as  to  render  ligatures  neceffary  j 

fary,  I  fliall  here  fliortly  mention  the  reafons  that  have  made  me  differ 
from  authorities  of  fuch  refpeiStability. 

That  this  operation  may  be  performed  without  dividing  more  mufcles 
than  the  tranfverfah"s  pcrinasi  and  levator  ani,  is  well  known  ;  but  it  is  not 
what  may  be  done,  but  what  ought  to  be  done,  that  In  all  important  op- 
erations demands  our  attention  ;  on  the  point  in  queftion,my  opinion  has 
alwavs  been,  that  all  thofe  mufcles  fliould  be  cut  that  are  apt  to  be  brulf- 
ed  or  torn  in  extraiSling  the  ftone :  now,  this  is  fo  clearly  the  cafe  with 
the  eredtor  penis  and  accelerator  urinns,  that  few  will  doubt  of  the  pro- 
priety  of  dividing  them  who  have  infpedted  them  in  patients  dying  after 
the  extrafting  of  large  flones:  wlienever  a  ftone  has  been  large  and  difii- 
cult  to  extraifb,  T  have  always  found  thefe  mufcles  much  contufcd,  often 
lac-;rared,  and  commonly  in  a  ftate  of  mortification.  Whereas,  when  com- 
pletely cut  acrofs,  this  does  not  fo  readily  happen;  the  divided  ends  of 
the  mufcles  retraA;  they  are  thereby  faved  from  the  violent  prefTure  of 
the  forceps  and  flone  ;  and  the  operation  is  finillied  with  much  more  eafe 
than  it  otherwife  poflQbly  could  be. 

Having  long  oblerved  this  to  be  the  cafe ;  knowing  that  no  danger  could 
enfue  from  dividing  them,  for  it  is  daily  done  with  impunity  to  a  much 
greater  extent  in  fululous  or  fmuous  ulcers  of  thefe  parts,  and  finding  up- 
on trial  that  the  more  freely  they  v/ere  cut,  the  more  fuccefsful  the  oper- 
ation commonly  proved,  I  have  therefore  long  been  in  the  practice  of  do- 
ing it :  my  operations  indeed  have  proved  fuccefsful  nearly  in  proportion 
to  the  freedom  with  which  thefe  parts  have  been  divided,  at  the  fame 
time  that  the  wounds  have  healed  more  kindly  than  when  fmall  openings 
have  been  made. 

Neither  has  this  divifion  of  thefe  parts  any  influence  on  the  diredlion 
of  the  external  cut,  which  ought  to  be  in  the  line  that  I  have  mentioned, 
beginning  nearly  an  inch  below  the  terminatian  of  the  fcrotum,  a  very  lit- 
tle to  the  left  of  the  rapha,  and  proceeding  obliquely  along  the  fame  fide 
of  the  perinreum,  till  it  runs  at  an  equal  diftancc  between  the  tuberolity 
of  the  ifchium  and  the  anus. 

If  the  fkin  and  cellular  fubftance  have  been  freely  divided,  they  retradl 
fo  much,  that  all  the  mufcles  that  I  have  mentioned  may  be  cut  with  cafe  : 
this  indeed  is  not  often  done ;  by  which,  flones  even  of  no  great  bulk  arc 
extradled  wth  difficulty  to  the  operator,  and  with  perfedt  torture  to  the 
patient ;  by  which  lives  are  often  brought  into  hazard,  and  even  loft, 
which  otherwife  might  be  faved. 

I  have  infifted  the  more  upon  this,  as  I  conceive  it  to  be  one  of  the  mofl 
important  points  in  this  very  interefting  operation  ;  one  on  which  the  fuc- 
cefs  attending  it  mufl  at  all  times  in  a  great  meafure  hinge;  and  particu- 
larly from  my  having  witnefTed  more  difaflrous  confequcnces  from  a  tim- 
idity in  regard  to  it,  that  is,  from  the  mufcles  not  being  freely  divided, 
than  from  all  other  failures  on  the  part  of  the  furgeon. 


Sea.  VII.  Of  the  Stone,  19! 

but  whenever  they  prove  to  be  fo,  and  efpecially  when 
the  patient  is  weak  and  emaciated,  the  larger  arteries 
ihould  be  immediately  fecured  before  the  furgeon  pro* 
ceeds  to  the  other  flops  of  the  operation. 

In  proceeding  to  finifli  the  operation,  furgeons  not 
unfrequently  open  the  urethra  higher  than  it  ought  to 
be  cut,  and  pafs  the  knife  into  the  fubftance  of  the 
bulb  itfelf.  But  this  adds  greatly  to  the  hazard  of  the 
operation  :  for,  the  blood  veflels  of  the  bulb  are  not 
only  large,  but  finufes  are  much  more  apt  to  form  in 
it  than  in  other  parts  of  the  penis,  by  which  the  cure 
of  the  wound  is  rendered  much  more  tedious  when 
this  part  is  divided  ;  and  not  being  necellary,  it  ought 
always  to  be  avoided.  When,  therefore,  the  incifion 
of  the  mufcles  is  finifhed,  the  operator  ought  to  fearch 
for  the  flaff  with  the  index  of  his  left  hand  ;  and  hav- 
ing found  it,  he  fliould  pufh  the  point  of  his  finger 
along  the  courfe  of  it  till  he  palTes  the  bulb,  when, 
with  the  edge  of  his  knife  turned  towards  the  groove 
of  the  rtalF,  he  fliould  divide  the  membranous  part  of 
the  urethra  in  its  whole  courfe,  from  the  bulb  to  the 
proflate  gland ;  and  the  finger  being  thus  ufed  as  a 
dire£tor,  while  by  means  of  it  the  redlum  is  complete- 
ly guarded,  this  incifion  of  the  urethra  may  be  made 
with  entire  fafety.  There  is  in  general,  indeed,  fuch 
a  quantity  of  cellular  fubflance  between  the  urethra 
and  redum,  that  in  this  part  of  the  operation  the  gut 
cannot  poffibly  be  hurt,  if  the  furgeon  is  not  either 
very  unfleady  or  inattentive  :  and  by  means  of  the 
precaution  I  have  advifed,  of  keeping  the  forefinger 
of  the  left  hand  always  between  the  knife  and  the  in- 
tefline,  it  may  in  this  manner  be  in  every  inftance  very 
certainly  avoided. 

The  incifion  of  the  urethra  being  finifhed,  the  prof- 
tate  gland,  which  we  readily  difcover  with  the  finger 
at  the  bottom  of  the  wound,  is  next  to  be  divided. 
In  the  hands  of  an  expert  furgeon,  the  operation 
might  be  finiflied  with  the  fame  fafety  with  the  fcal- 
pel  as  with  any  other  inflrument :  for,  by  continuing 


I9«  Of  the  Stone,  Chap.  XXIX. 

the  inclfion  of  the  urethra,  and  carrying  on  the  fcal- 
pel  fo  as  to  divide  the  proftate  gland  laterally,  if  the 
finger  is  ftill  continued  between  the  knife  and  the  rec- 
tum, no  rifk  could  enfue  from  it :  but  as  this  part  of 
the  operation  is  performed  entirely  by  feeling,  without 
the  aflillance  of  the  eyefight ;  and  as  many  operators 
are  not  fo  much  accultomed  to  this,  as,  in  fuch  cir- 
cumftances,  to  be  fufficiently  fteady,  the  redtum  might 
be  often  injured  were  the  fcalpel  to  be  commonly  em- 
ployed for  completing  the  operation. 

This  inconvenience,  however,  of  wounding  the  rec- 
tum, may  with  certainty  be  avoided,  by  ufmg  a  cut- 
ting director,  or  gorget,  as  it  is  termed,  inftead  of  a 
fcalpel :  this  alteration  of  the  gorget  was  lirfl  propof- 
ed  by  Mr.  Hawkins  of  London :  in  Plate  LXXI.  fig, 
4.  a  view  is  given  of  this  ;  and  in  the  fame  Plate,  and 
likewife  in  Plates  LXX.  LXXII.  and  LIX.  and  LX.  I 
have  delineated  different  improvements  that  have  been 
propofed  upon  this  inftrument  of  Mr.  Hawkins. 

The  gorget  of  Mr.  Hawkins  is  contracted  too  much 
at  the  cutting  part  of  it,  by  which  it  does  not  divide 
the  proftate  gland  fufficiently.  Were  we  to  ufe  a  gor- 
get much  wider  in  the  cutting  part  of  it,  the  divifion 
of  the  proftate  gland  might  indeed  be  made  extenfive 
enough  ;  but  it  is  not  done  by  the  gorget  in  common 
ufe,  fo  that  the  divifion  of  this  gland  is  commonly  too 
fmall,  either  for  the  extraction  of  a  (tone,  or  even  for 
the  introdudion  of  the  forceps,  without  much  lacera- 
tion ;  a  circumftance  that  in  every  inftance  fhould  be 
guarded  againft. 

The  gorget  in  ordinary  ufe,  while  it  is  too  narrow 
in  the  cutting  part  of  it,  is  too  wide  behind  ;  a  form 
which  the  leaft  reflection  muft  Ihew  to  be  not  only  un- 
neceffary  but  hurtful ;  for,  after  the  divifion  of  the 
proftate  gland,  the  only  ufe  of  the  gorget  is  to  ferve 
as  a  conductor  to  the  forceps  ;  and  as  this  purpofe  is 
anfwered  equally  well  by  a  director  that  does  not  ex- 
pand to  near  the  extent  of  the  gorget,  it  is  obvioufly 
improper  to  have  this  inftrument  fo  wide  as  it  is  com- 


Sed.  VII.  Of  the  Stone.  193 

monly  made.  But  farther,  the  impropriety  of  this 
conftruction  is  ftill  more  evident,  when  we  compare 
the  fize  of  the  common  gorget  with  the  parts  through 
which  it  has  to  pafs  :  for  it  is  obvious,  that  it  mufl 
greatly  injure  the  urethra ;  the  back  part  of  the  inftru- 
ment  being  fo  wide  and  deep,  as  to  render  it  impofli- 
ble  to  pafs  it,  without  much  laceration. 

The  cutting  diredor,  Plate  LXX.  fig.  2.  as  well  as 
the  gorget,  Plate  LXXI.  fig.  2.  will  be  found  to  pof- 
fefs  all  the  advantages  of  the  common  gorget,  without 
any  of  its  inconveniencies  :  the  cutting  part  of  both 
expands  more  than  that  of  the  common  gorget,  fo  that 
they  divide  the  proilate  gland  more  freely  ;  and  as 
the  blunt  part  of  them  is  much  contracted,  they  do 
not  lacerate  the  urethra  on  being  puflied  forward. 
To  thofe  who  have  never  ufed  thefe  inftruments,  and 
who  thereby  may  have  a  partiality  for  the  common 
gorget,  thefe  inltruments  may  perhaps  appear  not  to 
be  Sufficiently  wide  for  conducing  the  forceps :  this, 
however,  is  not  the  cafe  ;  and  it  will  foon  be  found, 
that  they  are  not  only  more  eafily  introduced  than  the 
common  gorget,  but  that  they  anfwer  equally  well  for 
conducting  cither  the  finger  or  forceps. 

It  has  been  objected  to  thefe  inftruments,  that  they 
will  not  make  fuch  a  free  divifion  of  the  mufcles  as  is 
done  by  the  common  gorget.  This,  however,  pro- 
ceeds from  prejudice  in  favour  of  an  inftrument  with 
which  pratlitioners  are  as  yet  better  acquainted,  and 
which  has  indeed  been  defer\^edly  much  employed ; 
but  it  is  thrown  out  without  due  refleftion  on  its  im- 
port. I  have  already  endeavoured  to  inculcate  the 
neccflity  of  a  free  divifion  of  the  teguments  and  muf- 
cles in  this  operation ;  but  whoever  confiders  this 
point  with  attention,  will  fee,  that  this  ought  to  be 
done  with  the  fcalpel  alone,  and  that  it  fhould  not  de- 
pend in  any  degree  upon  the  gorget :  all  that  fhould 
be  left  for  the  gorget  or  cutting  direftor  to  do,  is  to 
divide  the  proftate  gland  with  a  fmall  portion  of  the 

Vol.  III.  Q 


194  Of  the  Stone,  Chap.  XXIX* 

neck  of  the  bladder.  Some  practitioners,  indeed,  have 
recommended  inflruments  for  carrying  the  incifion  in- 
to the  body  of  the  bladder  ;  but  this  is  a  very  hazard- 
ous attempt,  and  not  in  any  refped:  neceflary :  for  as 
foon  as  the  proftate  gland  and  neck  of  the  bladder  are 
divided,  the  forceps  are  palied  with  eafe ;  and  ths 
bladder  itfelf  is  fo  eafily  dilated,  that  it  readily  yields 
to  the  paiTage  of  the  flone,  however  large  it  may  be. 
What  I  wifh  to  have  underflood,  is,  that  it  is^not  the 
fize  of  the  wound  in  the  bladder  that  renders  the  ex- 
tradion  of  flones  eafy  or  difficult ;  and  that  it  is  on 
the  previous  incifion  of  the  mufcles  and  proflate  gland 
that  this  almoft  entirely  depends. 

The  membranous  part  of  the  urethra  being  divided 
by  the  fcalpel  in  the  manner  I  have  advifed,  the  nail 
of  the  index  of  the  left  hand  iliould  be  introduced  in- 
to the  groove  of  the  flaff,  to  ferve  as  a  conductor  to 
the  point  or  beak  of  the  cutting  director  or  gorget. 
The  furgeon  having  no  further  occafion  for  the  fcal- 
pel, muft  now  lay  it  afide ;  and  having  paifed  the 
point  of  the  director  or  gorget  along  his  finger  into 
the  groove  of  the  flaff,  he  is  now  to  take  the  handle 
of  that  inflrument  from  the  afTiftant,  and  having  raif- 
ed  it  from  the  groin  of  the  patient  in  which  it  lay,  he 
mufl  with  his  left  hand  preferve  it  firm  in  this  fitua* 
tion,  while  with  his  right  he  puflies  on  the  cutting  di- 
rector or  gorget  till  it  has  paffed  freely  into  the  blad- 
der ;  a  point  of  the  operation  that  he  knows  is  accom* 
plifhed  when  the  urine  is  perceived  to  rufh  with  free* 
dom  out  at  the  wound.  In  executing  the  firfl  part  of 
the  operation,  the  furgeon  fhould  be  firmly  feated  j 
but  in  pafling  the  gorget  or  diredor  into  the  bladder^ 
as  likewife  in  extrading  the  flone,  he  fhould  fland 
immediately  before  the  patient,  as  in  this  poflure  thefg 
fleps  of  it  are  more  eafily  performed. 

It  is  a  point,  I  may  remark,  of  the  firfl  importance 
in  this  operation,  to  raife  the  fta£f  to  a  proper  height 
before  pufliing  on  the  gorget.  The  handle  of  the 
ftafl'  fhould  form  nearly,  though  not  entirely,  a  right 


Sea.  VII.  Of  the  Stone,  195 

angle  with  the  body  of  the  patient ;  and  if  kept  fuf- 
ficiently  firm  in  this  pofition,  the  gorget  or  director 
inay  be  puflied  on  with  fafety,  as  the  beak  of  the  in- 
ftrument,  if  this  direction  of  the  flaff  is  continued,  can 
fcarcely  efcape  from  the  groove  in  which  it  runs.  But 
if  the  elevation  of  the  ftalf  is  either  much  more  or  lefs 
than  this  when  the  gorget  is  puflied  forward,  the  point 
of  the  gorget,  inflead  of  pafling  into  the  bladder,  mufl 
be  forced  out  of  the  groove,  and  pafTing  between  the 
redum  and  bladder,  or  between  the  bladder  and 
pubes,  it  muft  here  do  a  great  deal  of  harm.  I  have 
known  even  expert  furgeons,  from  an  unpardonable 
degree  of  inattention,  fall  into  this  error  with  regard  to 
the  height  of  the  flaff.  Younger  practitioners,  there- 
fore, cannot  be  too  much  on  their  guard  againfl  it. 

Even  the  greatefl  attention,  however,  to  the  eleva- 
tion of  the  ftaff,  will  not  of  itfelf  prove  fuflicient.  The 
furgeon  ought  previoufly  to  fee  that  the  director  or 
gorget  is  exa£lly  fitted  to  the  groove  intended  to  re- 
ceive it ;  for  if  not  properly  adapted  to  each  other, 
the  gorget  will  not  run  eafily,  and  may  therefore  be 
very  readily  puflied  out  of  the  groove  of  the  ftaff. 

With  the  view  of  rendering  this  part  of  the  opera- 
tion fafe,  different  inventions  have  been  propofed  for 
fixing  the  beak  of  the  gorget  in  the  groove  of  the 
flaff,  fo  as  to  prevent  it  from  getting  out  till  it  has 
paded  into  the  bladder :  but  all  of  thefe  gives  fome 
difficulty  in  pafling  the  initrument ;  and  befides,  they 
do  not  appear  to  be  neceffary,  as  no  operator  can  pof- 
fibly  go  wrong,  but  from  grofs  mifconduct  or  inatten- 
tion. 

As  foon  as  the  gorget  has  freely  entered  the  blad- 
der, the  flaff  fhould  be  withdrawn ;  and  this  being 
done,  the  next  flep  in  common  pradice  is,  to  intro- 
duce the  forceps  immediately ;  but  as  the  flone  may 
be  frequently  felt  with  the  finger,  and  as  no  other 
method  ferves  fo  effectually  to  difcover  its  real  fitua- 
tion,  this  precaution  of  introducing  the  finger  into  the 
o  2 


196  Of  the  StoiK,  Chap.  XXIX* 

bladder  ought  never  to  be  omitted.  Ijttle  additional 
pain  is  given  by  the  introduction  of  the  finger,  and  if 
the  operator  is  lucky  enough  to  difcover  the  ftone,  he 
is  thereby  inftruded  \\\t\\  much  certainty  of  the  bed 
direftion  for  the  forceps. 

The  fituation  of  the  ftone  being  in  this  manner  dif- 
covered,  or  if,  upon  trial,  it  is  found  that  the  fmger 
will  not  reach  it,  forceps,  proportioned  to  the  fize  of 
the  patient,  are  to  be  palled  into  the  bladder  along 
with  the  gorget  or  director,  while  the  latter  is  imme- 
diately thereafter  to  be  withdrawn. 

In  an  operation  of  fuch  importance  as  this,  the  niofl 
trifling  circumftance  merits  attention  ;  for  the  more 
obvious  and  leading  parts  of  it  may  be  performed  in 
a  mafterly  manner,  and  yet  the  whole  may  fail  from 
want  of  attention  to  the  lefs  important  Iteps  of  it. 
Even  the  method  of  withdrawing  the  cutting  director 
or  gorget,  is  a  matter  that  requires  attention  ;  much 
more,  hideed,  than  it  commonly  meets  with.  After 
the  forceps  are  introduced,  the  gorget  fliould  be  flow- 
!y  withdrawn  in  the  exa£t  direftion  by  which  it  was 
entered  ;  for  if  turned  in  any  degree  either  to  one 
•fide  or  another,  it  muft  neceflarily  make  another  in- 
cifion,  not  only  in  the  proftate  gland,  but  in  ail  the 
^ther  parts  through  v/hich  it  is  made  to  pafs  ;  the  im- 
propriety of  which  is  too  obvious  to  require  further 
animadverfion. 

If  the  ftone  has  been  previoufly  difcovered  by  the 
finger,  it  is  commonly  eafily  laid  hold  of  with  the 
forceps ;  but  when  the  finger  has  not  been  able  to 
reach  it,  it  is  in  fome  inftances  with  much  difficulty 
met  with.  The  forceps  muft  neceiTarily  be  introduced 
{hut,  that  is,  with  their  blades  as  near  to  each  other 
as  their  form  admits  of  j  for,  with  a  view  to  prevent 
them  from  laying  hold  of  the  bladder,  they  fhould  be 
fo  conftrufted  as  not  to  meet  at  any  part  except  at 
their  axis,  by  at  leaft  the  tenth  part  of  an  inch.  But 
as  foon  as  they  have  entered  the  bladder,  they  fhould 
be  gradually  opened  ;   and   in  this  expanded  ftate 


Sea.  VII.  Of  the  Sione.  197 

fhould  be  eafily  moved  about,  with  their  handles 
fometimes  depreffed  and  fometimes  elevated,  till  the 
ftone  is  difcovered,  when  it  fhould  as  quickly  as  pof- 
fible  be  laid  hold  of.  It  frequently,  however,  hap- 
pens, even  with  expert  furgeons,  efpecially  when  the 
ilone  is  fmall,  that  it  is  not  readily  difcovered  by  the 
forceps.  In  fuch  inflances,  we  fometimes  meet  with 
it  near  to  the  fundus  of  the  bladder  j  but  it  is  mofl 
frequently  found  concealed  in  the  under  and  back 
part  of  it,  near  to  its  neck,  in  that  bag  that  I  have 
mentioned  as  being  formed  by  the  natural  prefTure  of 
the  urine.  When  it  is  difcovered  in  this  fituation, 
nothing  will  bring  it  fo  readily  into  contact  with  the 
forceps,  as  elevating  this  part  of  the  bladder  by  in- 
troducing the  finger  into  the  redum. 

In  general,  flraight  forceps,  fuch  as  are  reprcfented 
in  Plate  LXXV.  fig.  i.  and  2.  are  preferred  to  thofe 
that  are  much  crooked,  delineated  in  fig.  3.  For 
they  not  only  aft  with  more  power  in  extrading  the 
ftone,  but  ferve  equally  well  with  the  others  for  find- 
ing it.  Every  operator,  however,  fhould  be  provided 
with  all  the  varieties  of  forceps  now  in  ordinary  ufe. 

When  the  ftone  is  difticult  to  difcover,  the  furgeon 
is  apt  to  allege  that  it  proceeds  from  its  being  con- 
tained in  fome  preternatural  bag  or  cyft  ;  and  when 
laid  hold  of  with  the  forceps,  and  an  unufual  degree 
of  llrength  is  required  to  extrad  it,  this  is  commonly 
faid  to  arife  from  the  ftone  adhering  to  the  coats  of 
the  bladder.  That  the  weight  of  a  ftone  will  fome- 
times form  a  partial  cavity  for  itfelf,  by  prefling  that 
part  of  the  bladder  on  which  it  lies  into  the  neigh- 
bouring foft  parts,  there  is  no  rcafon  to  doubt  ;  and 
in  fome  inflances  the  bladder  is  found  fo  much  con- 
traded  round  a  Hone,  as  to  form  almofl  two  diftind 
bags.  This,  however,  is  rare  ;  and  the  adhefion  of 
ftones  to  the  bladder,  I  believe  to  be  flill  lefs  frequent, 
if  it  ever  takes  place.  Stones  have  indeed  been  fre- 
quently found  covered  with  the  coagulable  part  of  the 
blood,  which  in  fome  inftances  becomes  fo  firm  and 


198  Of  the  Stone.  Chap.  XXIX. 

tough,  as  to  have  the  appearance  of  an  organized 
membrane  ;  but  we  are  perfectly  unacquainted  with 
any  procefs  of  nature  by  which  an  adhefion  can  be 
produced  between  the  bladder  and  a  ftone  contained 
in  it. 

It  cannot  pofTibly  happen  by  any  communication  of 
blood  veiTels  betwixt  the  bladder  and  ftone  ;  and  it  is 
equally  improbable  that  it  can  be  produced  merely 
by  agglutination  ;  for,  by  the  intervention  of  the 
urine,  with  which  the  bladdefis  conftantly  moiften- 
ed,  fuch  an  effed  muft  be  with  certainty  prevented. 

But  it  is  not  reafoning  alone  that  militates  againft 
this  opinion.  For  although  fuch  an  occurrence  has 
been  frequently  mentioned  by  authors,  yet  we  do  not 
meet  with  one  authenticated  inftance  of  any  firm  ad- 
hefions  betwixt  the  bladder  and  ftones  contained  in  it 
being  difcovered  after  death.  I  am  therefore  led  to 
conclude,  that  this  idea  is  entirely  void  of  foundation  ; 
and  that  it  has  probably  arifen  from  the  mifconducl 
of  operators,  who,  by  making  the  external  incifion  too 
fmall,  or  not  dividing  the  mufcles  and  proftate  gland 
fufficiently,  have  experienced  much  difficulty  in  ex- 
trafting  a  ftone  of  even  a  moderate  fize,  and  who,  to 
efcape  cenfure,  have  fuggefted  the  poflibility  of  ftones 
adhering  to  the  internal  coat  of  the  bladder. 

When  the  ftone  is  laid  hold  of  with  the  forceps, 
the  operator,  before  he  proceeds  to  extract  it,  ought 
to  introduce  his  finger  into  the  bladder,  in  order  to 
difcover  whether  it  is  properly  fixed  in  the  forceps  or 
not.  This  in  various  inftances  proves  ufeful,  for  on 
finding  that  a  ftone  of  confiderable  length  is  laid  hold 
of  in  fuch  a  manner  as  to  have  its  longeft  diameter 
made  to  prefs  in  a  tranfverfe  diredlion  with  refpecl  to 
the  opening  in  the  bladder,  much  pain  and  laceration, 
which  would  undoubtedly  occur  from  extracting  it  in 
this  direction,  may  be  eafily  prevented,  either  by  turn- 
ing the  ftone  with  the  point  of  the  finger,  when  this 
can  be  done,  or  by  letting  it  flip  altogether  out  of  the 
forceps,  and  again  endeavouring  to  lay  hold  of  it  in  a 


Sea.  VII.  Of  the  Stone,  199 

more  favourable  pofition.  When  the  operator  is  cer- 
tain that  this  is  properly  done,  he  is  then  to  extract 
the  ftone  in  a  very  flow  and  gradual  manner.  The 
forceps  lliould  be  very  firmly  held  in  both  hands,  his 
right  being  applied  towards  the  extremity  of  the  han- 
dles, and  his  left  near  to  their  axis. 

In  common  practice,  if  the  ftone  does  not  coma 
readily  away,  the  force  made  ufe  of  is  applied  fo  as  to 
dilate  the  parts  equally  in  every  direction.  The  ftone 
is  made  to  move  not  only  upwards  and  downwards, 
but  laterally  ;  and,  by  fome,  even  a  rotatory  motion 
is  given  to  it.  Nothing,  however,  can  be  more  de- 
ftructive  than  this  to  the  parts  through  which  the  ftone 
muft  pafs,  while  at  the  fame  time  it  is  evidently  ill 
calculated  for  facilitating  the  extradion. 

Inftead  of  moving  the  ftone  in  this  manner,  the 
prefTure  ought  to  be  made  almoft  entirely  downwards  ; 
not  directly  from  the  fymphyfis  of  the  pubes  towards 
the  anus,  but  in  the  courfe  of  the  external  wound, 
which  ought,  as  I  have  already  obferved,  to  run  at  an 
equal  diftance  between  the  anus  and  tuberofity  of  the 
ifchium.  As  it  will  be  admitted,  that  the  force  em- 
ployed in  extracting  a  ftone  muft  prove  more  ufeful 
when  exerted  upon  parts  that  are  foft  and  of  a  yield- 
ing nature,  than  when  applied  immediately  upon  a 
bone  ;  fo,  whoever  attentively  confiders  the  anatomy 
of  the  parts  concerned  in  this  operation,  will  fee  the 
propriety  of  the  advice  I  have  given.  The  opening 
into  the  pelvis  is  at  this  place  fo  narrow,  that  a  very 
flight  examination  muft  render  it  evident,  that  in  ex- 
tracting a  ftone,  no  advantage  can  be  derived  from 
lateral  prelfure.  If,  again,  the  ftone  is  forced  upwards, 
it  muft  prefs  againft  the  bones  of  the  pubes  ;  for  this 
direction  nothing  intervenes  between  thefe  bones  and 
it,  except  the  urethra,  and  a  fmall  portion  of  cellular 
fubftance  :  and  if  directed  towards  the  anus,  it  mufl 
prefs  the  redum  againft  the  point  of  the  coccyx, 
which  will  not  only  give  much  immediate  diftrefs,  but 
muft  even  add  greatly  to  the  hazard  of  the  operation. 


200  Of  the  Stone,  Chap.  XXIX. 

The  rotatory  motion  which  in  this  operation  is 
fometimes  given  to  a  ftone,  unites  all  thefe  difadvan- 
tages  ;  but  by  can-ying  the  preflure  downwards  in  the 
courfe  of  the  wound,  fo  as  that  it  may  fall  between 
the  anus  and  ifchium,  every  inconvenience  of  this 
kind  is  avoided,  and  a  more  extenfive  dilatation  is  ob- 
tained than  can  be  procured  in  any  other  direction. 

By  gradual  preflure  in  this  direftion,  the  ftone,  if 
not  uncommonly  large,  will  for  the  moft  part  be  ex- 
tradled  at  laft  ;  but  when,  in  the  courfe  of  the  extrac- 
tion, the  operator  meets  with  much  refiftance  to  the 
ftone,  he  fhould  examine  the  ftate  of  the  divided 
parts,  and  if  any  part  of  the  mufcles  that  ought  to 
have  been  cut  are  ftill  found  entire,  they  fhould  be 
Immediately  divided  ;  and  the  eafieft  method  of  doing 
it,  is  to  fecure  the  ftone  in  the  forceps  with  the  left 
hand,  while  with  a  fcalpel  in  the  other,  a  complete, 
divifion  of  the  mufcles  is  accompliftied. 

With  a  view  to  prevent  the  forceps  from  prefllng 
fo  much  upon  the  ftone  as  might  break  it,  fome  pro- 
pofah  have  been  made  for  rendering  the  degree  of 
preflure  fteady  and  certain.  Of  thefe  the  beft  feems 
to  be  what  is  reprefented  in  Plate  LXXVI.  fig.  3.  in 
which,  as  foon  as  the  ftone  is  laid  hold  of,  it  is  pre- 
ferved  in  the  fame  pofition  by  means  of  a  fcrew  that 
pafl'es  from  one  of  the  handles  of  the  forceps  into  the 
other.  This,  however,  I  confider  as  a  very  unnecef- 
fary  addition  to  forceps  ;  for  when  a  ftone  is  fmall, 
no  furgeon  of  experience  will  apply  great  force  to  exf 
tra6l  it ;  and  when  of  a  large  fize,  it  will  be  more  for 
the  patient's  advantage  that  it  ftiould  break  than  be 
extracted  entire. 

I  have  fpoken  already  of  the  hazard  arifmg  from 
the  extraftion  of  large  ftones.  It  is  indeed  fo  confid- 
erable,  as  to  warrant  this  conclufion,  that,  casteris  pa- 
ribus, the  hazard  attending  lithotomy  may  be  confid- 
ered  as  correfponding  to  the  fize  of  the  ftone  to  be 
extracted.  In  healthy  fubjefts,  when  the  ftone  is 
fmall,  and  the  operation  properly  performed,  fcarcely 


Sea.  VIT.  Of  the  Strme.  20l 

one  in  twenty  die ;  but  although  a  few  have  recover- 
ed from  whom  flones  of  a  large  fize  have  been  taken, 
yet  whenever  the  flone  has  exceeded  feven  or  eight 
ounces  in  weight,  not  above  one  in  ten  recover. 

This  is  accordingly  a  very  important  circumftance, 
and  worthy  of  our  mofl  ferious  attention ;  and  although 
the  breaking  of  a  ftone  in  the  courfe  of  extraction,  is 
in  other  refpefts  difagreeable,  yet,  with  a  view  to  ob- 
viate the  dreadful  confequences  of  tearing  out  a  large 
ftone,  when  in  the  courfe  of  an  operation  it  is  found 
to  be  uncommonly  large,  and  that  it  cannot  be  taken, 
out  but  with  much  hazard  to  the  patient,  might  it  not 
be  more  eligible,  either  to  endeavour  to  break  it  with 
the  forceps  already  introduced,  or  to  withdraw  thefe, 
and  to  introduce  others  more  fit  for  the  purpofe  ?  In 
Plate  LX XVIII.  fig.  i.  is  delineated  forceps  of  this 
kind,  originally  invented  by  Andreas  a  Cruce,  and 
fmce  improved  by  Le  Clat  and  others :  by  means  of 
the  long  and  ftrong  teeth  with  which  they  are  fur- 
niflied,  and  efpecially  by  the  intervention  of  the  fcrew 
for  comprefiing  their  handles,  almoft  any  ftone  may 
be  broken  into  fmall  pieces  ;  and  this  being  effefted, 
the  diiierent  pieces  fall  to  be  extracted  with  common 
forceps. 

In  fuch  circum fiances,  however,  or  when  a  ftone  has 
broken  by  accident  in  the  courfe  of  an  operation,  the 
utmoft  care  is  neceffary  in  order  to  extract  every  frag- 
ment ;  for,  if  the  fmalleft  particle  is  left,  if  it  be  not 
afterwards  waflied  oft"  with  the  urine,  it  may  prove 
highly  detrimental,  by  ferving  as  a  nucleus  for  the 
formation  of  another  ftone.  After  all  the  larger  pie- 
ces have  been  extracted  with  the  forceps,  a  fcoop  re- 
prefented  in  Plate  LXXVIII.  fig.  2.  proves  fometimcs 
ufeful  for  taking  out  the  fmaller  particles  ;  but  for  this 
laft  purpofe,  nothing  anfwers  fo  well  as  injefting  large 
quantities  of  tepid  water  into  the  bladder,  either  with 
a  fyringe  or  bag  and  pipe.  This  may  be  done  with 
ejitire  fafety,  and  it  commonly  anfwers  the  purpofe  fpr 
which  it  is  employed. 


202  Of  the  Stone.  Chap.  XXIX. 

When  a  ftone  is  found  to  have  a  fmooth  polifhed 
furface,  it  is  the  common  opinion  that  others  muft  re- 
main in  the  bladder,  as  this  fmoothnefs  is  fiippofed  to 
arife  from  the  friclion  of  other  ftones  ;  while  a  rough 
unequal  furface  is  fuppofcd  to  denote  the  exiftence  of 
one  (tone  only.  No  dependence,  however,  fhould  be 
placed  on  thefe  circumftances  ;  for  we  daily  meet  with 
inftances  of  a  finglc  {iowo.  with  a  fmooth  furface  ;  and 
of  ftones  that  are  rough  and  unequal  leaving  more  than 
one  in  the  bladder.  As  foon,  therefore,  as  one  ftone 
is  extracted,  the  operator,  inftead  of  trufting  to  exter- 
nal appearances,  fhould  firft  fearch  the  wound  with 
his  fijiger,  as  far  as  it  will  reach,  and  then,  either  with 
common  forceps,  or  with  the  thick  cui-ved  inftrument 
reprefented  in  Plate  LXXII.  fig.  i.  which  may  be  term- 
ed a  fearcher,  and  which  anfwers  the  purpofe  better ; 
and  as  long  as  any  ftones  are  difcovered,  the  forceps 
ihould  be  repeatedly  introduced  till  the  whole  are  tak- 
en out. 

In  the  courfe  of  this  operation,  fome  blood  veflels, 
as  I  have  already  obferved,  are  unavoidably  divided  ; 
but  when  the  incifion  is  kept  fufficiently  low  in  the 
perinseum,  and  when  therefore  the  bulb  of  the  urethra 
is  avoided,  there  is  feldom  much  rilk  to  be  dreaded 
from  any  hemorrhagy  that  enfues.  It  fometimes, 
however,  happens,  that  thofe  branches  of  the  internal 
iliac  artery  that  fupply  the  parts  lying  anterior  to  the 
proflate  gland,  are  fo  confiderable,  as  to  pour  out  a 
good  deal  of  blood :  but  as  a  free  difcharge  during 
the  operation  is  the  beft  preventive  of  inflammation,  a 
fymptom  more  to  be  dreaded  than  any  other  arifmg 
from  Hthotomy,  nothing  in  general  ihould  be  done, 
except  in  very  weak  habits  of  body,  to  put  a  ftop  to 
the  hemorrhagy  till  all  the  ftones  are  extracted  ;  when, 
if  it  ftill  continues,  any  artery  that  appears  fhould  be 
fecured  with  a  lisjature  ;  and  if  the  external  incifion 
has  been  made  large  in  the  manner  I  have  advifed, 
this  part  of  the  operation  does  not  prove  fo  difficult 
as  is  commonly  imagined.     In  different  inftances,  I 


Sea.  VII.  Of  the  Stone.  203 

have  palled  a  ligature  upon  an  artery  almoft  as  deep 
as  the  proftate  gland  ;  and  when  a  large  veffel  has 
been  cut,  the  advantage  derived  from  this  efteftual 
method  of  fecuring  it,  is  of  itfelf  a  very  important  ar- 
gument for  making  the  external  incifion  in  every  in- 
ftance  free  and  extenfive. 

When,  however,  the  divided  veffel  cannot  be  fecur- 
ed  with  a  ligature,  we  are  then  to  endeavour  to  flop 
the  hemorrhagy  by  preffure  ;  and  for  this  purpofe  a 
firm  roller  introduced  at  the  wound  would  commonly 
anfwer ;  but  in  order  to  avoid  any  flop  to  the  flow  of 
urine,  inflead  of  a  folid  roller,  a  filver  canula  covered 
with  foft  linen  may  be  employed.  Of  this  inflrument 
I  have  given  a  reprefentation  in  Plate  LXXVllI.  fig.  3. 

Not\\'ithflanding,  however,  of  every  precaution, 
fome  of  the  deep  feated  arteries,  divided  in  the  opera- 
tion, continue  fometimes  to  pour  out  a  great  deal  of 
blood,  and  which,  inflead  of  palling  off  by  the  wound, 
is,  in  fome  inllances,  colle6led  in  great  quantities  in 
the  cavity  of  the  bladder.  As  foon  as  this  is  perceiv- 
ed, means  fliould  be  employed  for  removing  the  blood  ; 
and  the  mofl  eifeftual  are,  to  extract  as  much  of  it  as 
poffible,  by  a  proper  ufe  of  a  fcoop,  Plate  LXXVIII. 
fig.  2.  and  afterwards  by  injefting  warm  water  at  the 
wound,  to  wadi  off  the  remainder.  In  this  manner 
very  large  colleclions  of  blood  may  be  removed  ;  and 
when,  as  has  fometimes  happened,  means  of  this  kind 
have  not  been  employed,  the  coagulum  has  at  lafl  be- 
come fo  firm,  and  has  filled  the  cavity  of  the  bladder 
fo  much,  as  to  prevent  entirely  all  further  depofition 
of  urine.  In  this  cafe  the  belly  becomes  pained  and 
fwelled  ;  fever  takes  place  j  and  death  itfelf  very  com- 
monly fucceeds. 

With  a  viev/  to  prevent  this  unfortunate  iffue  with 
as  much  certainty  as  poliible,  every  patient  fliould, 
iunnediatcly  after  the  operation,  be  laid  in  fuch  a  pof- 
ture  as  may  v/ith  moll  certainty  tend  to  difcharge  any 
blood  that  may  fail  into  the  bladder.  Inflead  of  lay- 
ing the  head  low,  and  the  buttocks  high,  as  is  com- 


204  Of  the  Stone.  Chap.  XXir. 

monly  done,  the  pelvis  fhould  be  lower  than  the  rcfl 
of  the  body  ;  by  which  the  wound  is  kept  in  a  depend- 
ing poilure,  which  ferves  to  allifl  the  diicharge  of  any 
blood  that  the  arteries  may  pour  out.  As  foon  as  the 
flow  of  blood  is  flopped,  the  patient  ihould  be  untied, 
and  a  piece  of  foft  lint  being  infertcd  between  the  lips 
of  the  wound,  the  thighs  fhould  be  laid  together,  in 
which  pofition  he  fliould  be  carried  to  bed  ;  and  an 
opiate  being  given,  he  fhould  for  fome  time  be  left  en- 
tirely to  the  charge  of  an  experienced  nurfe.  No 
drefling  anlwers  fo  well  as  dry  lint ;  for  as  the  urine 
is  conflantly  pafTmg  off  by  the  wound,  and  as  the  parts 
are  thereby  kept  wet,  which  makes  them  apt  to  fret, 
a  frequent  renewal  of  drefTmgs  becomes  neceffary  ; 
and  nothing  is  either  more  eafily  appHed  or  removed 
than  a  piece  of  diy  lint. 

When  the  flone  has  not  been  difficult  to  extract, 
the  patient  generally  remains  free  from  much  pain  j 
and  he  frequently  falls  into  reft,  and  fleeps  during  the 
firft  three  or  four  hours  after  the  operation  :  but  when 
the  ftone  is  large,  and  much  violence  has  been  done 
to  the  parts  in  taking  it  out,  fevere  pain  in  the  under 
part  of  the  belly  often  fupervenes  in  the  fpace  of  an 
hour  or  two  from  the  operation ;  and  it  commonly 
proves,  when  not  fpeedily  removed,  to  be  one  of  the 
moft  alarming  fymptoms  that  takes  place.  When 
merely  fpafmodic,  ho\vever,  which  in  fome  inftances 
appears  to  be  the  cafe,  it  is  commonly  foon  removed 
by  the  ufe  of  warm  fomentations  to  the  belly,  or  by 
emollient  anodyne  injedions  thrown  into  the  redum. 

When  by  the  ufe  of  thefe  remedies,  the  pain  is  found 
to  abate,  little  or  no  anxiety  need  be  entertained  on 
account  of  it ;  but  when,  inftead  of  becoming  lefs  vi- 
olent, it  proceeds  to  increafe,  and  efpecially  when  the 
belly  becomes  hard  and  tumefied,  and  the  pulfe  full 
and  quick,  much  danger  is  to  be  dreaded.  As  thefe 
fymptoms  almofc  conftantly  proceed  from  inflamma- 
tion, blood  fliould  be  taken  in  quantities  proportioned 
to  their  violejice  ;  emollient  injections  fliould  be  con- 


Sea.  Vri.  Of  the  Sion.\  205 

tinued  ;  and  If  the  local  application  of  heat  to  the  ab- 
domen, either  by  warm  flannels,  or  by  warm  water 
contained  in  a  bladder,  does  not  anfwer,  the  patient 
fhould  be  immediately  put  into  a  femicupium.  In. 
fuch  circumllances,  indeed,  I  have  experienced  more 
advantage  from  this  than  from  any  other  remedy  ;  for 
it  not  only  conveys  the  heat  more  diredly  and  more 
fully  to  the  parts  affedted,  but  a  free  difcharge  of  urine 
by  the  wound  is  alfo  more  commonly  procured  by  it 
than  in  any  other  manner,  fo  that  much  relief  is  often 
obtained  from  it. 

A  due  perfeverance  in  thefe  means,  with  a  proper 
life  of  opiates,  a  low  diet,  and  a  free  ufe  of  diluent 
drinks,  will  frequently  remove  very  alarming  fymp- 
toms.  But,  in  fome  inftances,  all  our  efforts  prove 
fruitlefs :  the  pain  and  tenfion  of  the  abdomen  con- 
tinue to  increai'e  ;  the  wound,  inftead  of  putting  on  a 
florid,  healthy  appearance,  remains  floughy  and  pale, 
which  feldom  fails  to  precede  the  moft  alarming  fymp- 
toms  ;  the  pulfe  becomes  quick  and  feeble,  and  death 
clofes  the  fcene.  But,  w^hen  matters  terminate  happi- 
ly, the  wound  by  degrees  becomes  red  and  of  a  heal- 
thy afpeft  :  the  urine,  in  fome  infl:ances,  pafl'es  by  the 
urethra  from  the  firft  ;  but  in  moft  cafes  it  comes 
away  by  the  wound  for  the  firft  two  or  three  weeks  : 
the  pain  in  the  belly  gradually  abates  ;  and  any  fynip- 
toms  of  fever  which  prevailed  at  firft,  are  in  a  fhort 
time  entirely  removed. 

The  period  at  which  a  complete  cure  of  the  wound 
is  accompliflied,  is  exceedingly  various,  and  depends 
on  the  health  of  the  patient :  in  fome  few  cafes  of 
young  healthy  boys,  I  have  known  it  completely  cica- 
trifed  in  lefs  than  three  wrecks  ;  but  in  others,  not  till 
the  fixth,  feventli,  or  eighth  week.  In  fome  inftan- 
ces, again,  although  a  great  part  of  the  fore  may  heal 
rapidly,  yet  a  fmall  opening  will  remain,  at  which  the 
urine  continues  to  be  difcharged,  and,  the  edges  be- 
coming callous,  a  real  fiftula  is  produced,  that  cannot 
be  cured  but  by  another  operation  j  the  manner  of 


2o6  Of  the  Sionc,  Chap.  XXIX. 

performing  which  I  fliall  prefently  have  occafion  to 
mention.  Indeed  the  prevention  of  fiftulous  openings 
depends  much  on  proper  attention  in  drefling  the 
wound.  If  care  is  taken  to  introduce  the  Hnt  fuffi- 
ciently  within  the  hps  of  the  wound,  till  granulations 
fill  it  up  at  bottom,  there  will  feldom  be  any  rifk  of 
fiftulous  fores.  The  wound  ought  not,  however,  to 
be  crammed,  either  with  lint  or  any  other  drcfling  ; 
for  in  this  cafe  the  edges  muft  either  inflame,  or  ac- 
quire a  morbid  hardnefs.  In  other  refpects,  the  treat- 
ment fliould  be  nearly  fuch  as  is  known  to  anfwer  in 
fimilar  wounds  in  other  parts.  It  is  proper,  however, 
to  obferve,  that  nothing  removes  that  excoriation  of 
the  buttocks  with  fuch  certainty,  which  fometimes 
proves  troublefome  after  this  operation,  from  their  be- 
ing kept  conftantly  wet  with  the  urine,  as  frequent 
bathing  with  brandy  or  lime  water. 

Where  the  confiitution  is  enfeebled,  incontinence 
of  urine  is  apt  to  fucceed  to  this  operation  ;  for  the 
removal  of  which  nothing  proves  fuccefsful  till  a  re- 
covery of  ftrength  has  taken  place.  A  light  invigo- 
rating diet,  together  with  the  ufe  of  the  cold  bath  and 
Peruvian  bark,  are  therefore  our  principal  remedies. 
But,  in  order  to  obviate  the  immediate  difagreeable 
effect  of  a  conftant  difcharge  of  urine,  different  inftru- 
ments  have  been  invented.  Some  of  thefe  have  in 
view  the  compreflion  of  the  penis,  in  order  to  prevent 
the  urine  from  being  difcharged  ;  and  others,  while 
they  are  fo  formed  as  to  be  concealed  within  the  pa- 
tient's breeches,  are  meant  to  ferve  as  receptacles  for 
the  urine  on  its  paffing  from  the  urethra. 

In  Plate  LXXVII.  fig.  i.  is  reprefented  the  moft  I 
convenient  form  of  the  firft  of  thefe  ;  and  in  fig.  2. 
of  the  fame  Plate,  as  well  as  in  Plate  LV.  fig.  2.  are 
delineated  receivers,  which  by  experience  have  been 
found  to  anfwer  the  purpoie  of  the  latter  both  with 
cafe  and  certainty  ;  and  they  may  alfo  be  ufed  in  all 
cafes  of  incontinence  of  urine,  whethei-  arifing  front 
this  operation  or  any  other  caufe. 


Sea.  Vn.  Of  ihc  Stotie.  207 

While  from  the  fliortnefs  of  the  urethra  In  women, 
they  are  lefs  liable  to  the  ftcne  than  men,  the  opera- 
tion of  lithotomy  with  refped:  to  them,  is,  on  the  fame 
account,  much  more  fnnplc,  and  of  courfe  more  eafily 
performed,  and  accompanied  with  lefs  hazard.  It  can- 
not be  done  by  cutting  from  the  perina^um,  in  the 
fame  manner  as  in  male  fubjefts  ;  for,  as  the  urethra 
and  bladder  lie  immediately  above  the  vagina,  any 
opening  made  into  them  from  the  perlnteum,  would 
pafs  through  the  vagina,  fo  as  to  wound  it  both  above 
and  below.  There  is  no  necefiity,  however,  for  hurt- 
ing the  vagina,  as  the  urethra  may  be  divided  from 
one  end  to  the  other,  without  any  rifk  of  touching  it. 

The  patient  being  placed  upon  a  table,  and  fecured 
in  the  manner  I  have  already  advifed  for  male  fubjects, 
a  grooved  ftaff,  fuch  as  is  reprefented  in  Plate  LXX. 
fig.  5.  is  to  be  introduced  into  the  bladder,  by  paiTmg 
it  along  the  urethra,  which  lies  between  the  nympha;, 
immediately  below  the  clitoris  ;  and  the  operator, 
keeping  the  flaff  firm  with  his  left  hand,  mufl:  with  his 
right  introduce  the  beak  of  the  cutting  dIre£tor,  fig.  i. 
of  the  fame  Plate,  or  of  the  gorget,  fig.  2.  Plate  LXXI. 
into  the  groove,  and  then  pulli  it  eafily  along  till  it  has 
fairly  entered  the  bladder.  The  fl:aff  is  now  to  be 
withdrawn,  when  the  operator,  as  in  male  fubjects, 
fhould  introduce  his  finger  along  the  direftor ;  and. 
having  difcovered  a  ftone,  fliould  proceed  to  extra<^ 
it  in  the  manner  I  have  already  advifed. 

By  the  old  method  of  cutting  in  females,  namely, 
with  the  greater  apparatus,  no  inclfion  was  made  into 
the  urethra,  but  different  inft:ruments  were  ufed  for 
dilating  it ;  and  this  being  done,  the  forceps  were  em- 
ployed for  extrading  the  Itonc.  In  this  manner,  how- 
ever, the  parts  were  much  lacerated ;  the  patient  fuf- 
fered  a  great  deal  of  unneceffary  pain,  and  the  blad- 
der was  commonly  deprived  of  all  power  of  retention. 
I  have  therefore  no  helitation  in  giving  a  preference  to 
the  method  of  operating  that  I  have  pointed  out,  in 


2o8  Of  the  ^ione.  Cliap.  XXIX. 

which  the  urethra  is  cut  through  its  whole  length,  in- 
jflead  of  being  lacerated  or  torn. 

As  the  bladder  in  females  lies  immediately  above, 
and  quite  contiguous  to,  the  vagina,  it  has  been  pro- 
pofed,  that,  inllead  of  laying  open  the  urethra,  as  I 
have  advifed,  an  opening  fliould  be  made  directly  into 
the  bladder  from  the  vagina,  at  which  the  forceps  are 
to  be  introduced  for  extrading  the  (tone.  One  cafe 
of  this  kind  is  recorded  by  BulFiere  ;*  and,  more  late- 
ly, other  three  are  related  by  the  late  Mr.  Gooch,  in 
which  this  method  of  extraftion  was  fuccefsfully  em- 
ployed.! It  has  never,  however,  been  generally 
adopted  ;  and  as  various  objections  occur  to  it,  I  do 
not  fuppofe  that  it  will  ever  be  frequently  praO:ifed. 

By  cutting  into  the  bladder  through  the  vagina, 
parts  are  injured,  which  by  the  other  method  are 
avoided  :  the  ftone,  when  it  does  not  lie  diredtly  up- 
on the  vagina,  is  with  difficulty  laid  hold  of ;  it  can- 
not be  fo  eafily  extracted  as  when  drawn  along  the 
courfe  of  the  urethra  ;  fiflulous  openings  mufl  proba- 
bly occur  more  frequently  after  this  method  of  oper- 
ating than  after  the  other  ;  and  if  the  woman  Ihould 
afterwards  become  pregnant,  the  cicatrix  formed  in 
the  vagina  would  produce  pain,  obftruction,  and  per- 
haps laceration  in  the  time  of  delivery. 

One  great  advantage  derived  from  the  lateral  oper- 
ation, in  its  prefent  improved  ftate,  both  in  males  and 
females,  is,  that  no  laceration  takes  place  if  the  ftone 
be  not  remarkably  large ;  in  which  cafe,  no  precau- 
tion can  altogether  prevent  it :  but,  in  a  great  propor-j 
tion  of  cafes,  if  the  parts  are  freely  divided  in  the] 
manner  I  have  advifed,  all  the  rifk  attending  lacera*i 
tion,  and  which  I  have  endeavoured  to  point  out  as 
the  mod  hazardous  part  of  this  operation,  is  avoided 
with  certainty. 

*  Philofopliical  Tranfadtiona  for  the  year  1669,  p.  106. 

t  Vide  Cafes  and  Remark*  ia  Surgery,  volume  ii.  p.  182,  by  Benjamiu 
Gooch. 


Sed.  VII.  Of  the  Stone,  409 

I  have  thus  defcribed  the  various  means  which 
hitherto  have  been  employed  by  praditioners,  for  ex* 
trading  ftones  from  the  bladder  ;  and  from  what  has 
been  faid,  it  appears,  that  the  lateral  operation  is,  in 
ordinary  cafes,  greatly  preferable  to  every  other.  It 
ftands  indeed  fo  eminently  fuperior  to  the  others  for 
general  ufe,  that  it  does  not  appear  neccffary  to  draw 
any  farther  comparifon  between  them  ;  but,  as  I  have 
already  obferved,  particular  cafes  fometimes  occur,  ill 
which  the  high  operation  may  with  propriety  be  em- 
ployed inftead  of  it :  I  have  already  in  ftrong  terms 
pointed  out  the  rifk  of  extrading  a  large  flone  by  the 
lateral  operation  ;  and  T  have  Ihown,  that  ftones  of 
any  magnitude  that  the  bladder  can  contain,  may  be 
taken  out  by  the  high  operation.  When,  therefore, 
it  is  with  tolerable  certainty  known,  that  a  ftone  is 
imcommonly  large,  and  when  the  high  operation  is  in 
other  refpeds  admiflible,  it  ought  certainly  in  every 
fuch  inftance  to  be  preferred  :  for  although  where 
ftones  are  large  it  may  be  better  to  break  them  into 
fmall  pieces  in  the  manner  I  have  advifed,  than  to 
lacerate  the  parts  by  taking  them  out  entire  ;  yet  the 
pradice  is  only  proper  when  the  operator  unexped- 
edly  meets  with  a  large  ftone  after  the  bladder  has 
been  cut  into  ;  fo  that  wherever  it  is  previoufly  known 
that  a  ftone  is  large,  much  advantage  may  be  derived 
from  a  judicious  choice,  on  the  part  of  the  operator, 
of  his  method  of  operating. 

In  the  diredions  that  I  have  given  for  performing 
the  lateral  operation,  the  didates  of  experience  are 
ftridly  adhered  to,  and  I  have  recommended  nothing 
that  is  not  either  at  prefent  very  generally  adopted, 
or  that  I  have  not  myfelf  put  in  pradice. 

Many  propofals  have  been  made  by  individuals  for 
the  improvenient  of  the  operation  of  lithotomy,  par- 
ticularly of  the  lateral  method  of  performing  it ;  but 
a  minute  detail  of  all  that  has  been  fuggefted  upon 
the  fubjed,  is  incompatible  Vvith  the  nature  of  this 

Vol.  III.  P 


2IO  Of  the  ^ lone.  Chap.  XXIX, 

work ;  nor  could  it  ferve  any  pUrpofe,  but  to  bring 
into  view  fome  particular  modes  of  pradice,  which 
were  either  never  generally  followed,  or  which,  if 
adopted,  have  fallen  again  into  difufe. 

The  moft  remarkable  of  thefe  propofed  improve- 
ments of  the  lateral  operation,  are  thofe  of  three  French 
furgeons,  Monfieur  Foubert,  Monfieur  Thomas,  and 
Frere  Cofme.  The  two  firft,  invented  inflruments 
for  penetrating  the  body  of  the  bladder,  without 
wounding  the  urethra.  The  bladder  beincj  diftended 
with  urine,  and  an  incifion  made  through  the  fkin  and 
cellular  fubftance,  a  cutting  inftrument  of  a  particular 
conftruction  is  then  puflied  pad  the  urethra  into  the 
fide  of  the  bladder  ;  and  an  opening  being  made  of  a 
fufficient  fize,  the  ftone  is  extracted  in  the  ufual  man- 
ner. One  material  advantage  expefted  from  this  is, 
that  by  the  urethra  and  proftate  gland  being  avoided, 
that  inability  to  retain  the  urin^e,  and  other  trouble- 
fome  confequences,  which  fometimes  enfue  from  in- 
juries done  to  thefe  parts,  are  not  fo  apt  to  occur 
when  the  body  of  the  bladder  alone  is  wounded.  But, 
independent  of  other  objections  to  which  this  method 
of  operating  is  Hable,  the  wound  in  the  bladder  being 
fure  to  recede  froni  the  wound  in  the  teguments  as 
foon  as  all  the  water  contained  in  it  is  difcharged,  will 
probably  prevent  it  from  being  ever  adopted  ;  for  the 
urine,  not  finding  a  free  paffage  by  the  wound,  muft 
pafs  into  the  contiguous  parts,  where  it  mufl  always 
excite  very  diftrefsful  confequences. 

So  that  although  this  method  of  cutting  directly 
into  the  neck  or  body  of  the  bladder,  is  at  firft  viewj 
extremely  plaufible,  yet  the  leaft  reflection  on  the  con- 
fequences that  it  would  excite,  muft  at  once  bring 
conviction  of  the  rifk  that  would  refult  from  it. 

The  operation  of  Frere  Cofme  is,  in  efte(ft,  the 
{fame  with  the  lateral  operation,  as  it  is  now  common- 
ly pradtifed.  The  parts  that  are  cut  in  it  are  exactly 
the  fame,  only  they  are  divided  in  a  different  manner, 
'After  the  ftaff  is  laid  hare  in  the  ufual  manner,  the 


Sea.  VII.  Of  the  Sme.  Sii 

beak  of  the  inftrument,  fig.  i.  Plate  LXXVI.  is  Intro- 
duced into  the  groove  ;  and  being  puflied  forward  till 
it  reaches  the  bladder,  the  fpring  E  is  then  prelTed 
down,  fo  as  to  raife  the  knife  from  its  fheath,  when 
the  operation  is  finifhed  by  withdrawing  the  inftru- 
ment  in  fuch  a  direction  as  may  divide  the  neck  of 
the  bladder  and  proftate  gland,  in  the  fame  manner  as 
is  done  by  the  common  gorget :  after  this,  the  other 
fteps  of  the  operation  are  to  be  completed,  in  the 
manner  direfted  above  with  forceps. 

Mofl  of  the  other  deviations  from  the  eftablifhed 
mode  of  pradice,  hitherto  propofed  by  furgeons,  con- 
fift,  either  in  feme  improvements  of  the  cutting  gor- 
get of  Mr.  Hawkins,  or  in  a  preference  which  fome 
pra6litioners  Itill  continue  to  give  to  the  knife.  I  have 
already  obfcrved,  that  Mr.  Hawkins*  gorget  does  not 
fpread  fujBiciently  at  the  cutting  part  of  it,  and  that  it 
is  wider  and  deeper  behind  than  it  ought  to  be,  by 
which  it  is  liable  to  tear  and  otherwife  injure  the  ure- 
thra more  than  is  neceffary.  This  inconvenience, 
however,  is  removed  by  the  cutting  director  that  I 
have  ventured  to  recommend,  as  delineated  in  Plate 
LXX.  and  in  a  great  degree  by  the  gorget,  fig.  i.  and 
2.  Plate  LXXI. 

In  regard  to  the  preference  given  by  fome  to  thq 
fcalpel,  not  only  to  the  diredor,  but  to  the  cutting 
gorget,  I  have  only  to  obferve,  that  an  expert  furgeon 
of  fteadinefs,  and  pofl'efling  a  minute  knowledge  of  the. 
anatomy  of  the  parts,  may  with  eafc  and  fafety  per- 
form the  operation  with  the  knife  alone ;  but  I  mufl 
alfo  remark,  that,  when  the  fcalpel  only  is  employed, 
the  danger  of  wounding  the  reftum  would  in  common 
pradice  be  very  great,  fo  that  the  gorget  or  cutting 
direftor,  by  either  of  which  the  gut  is  completely  de- 
tended,  ought  to  be  commonly  preferred. 

In  the  courfe  of  this  fe6tion,  I  have  endeavoured  to 
deliver  all  that  is  worth  recording  of  modern  pradice 
in  the  operation  of  lithotomy  :  I  am  not  confcious  of 
p  2 


212  Of  the  ^mc.  Chap.  XXIX. 

having  omitted  any  improvements  of  importance  ;  and 
I  hope  it  will  appear  that  I  have  propofed  fome  that 
are  not  generally  l^nown,  or  which,  if  known,  are  not 
commonly  praclifed. 

The  operation  of  lithotomy  being  one  of  the'  mofl 
important  in  the  department  of  furgery,  I  have  been 
induced  to  extend  this  fection  to  a  great  length :  it 
may  therefore  prove  acceptable,  to  ftudents  efpecially, 
to  have  fuch  circumftances  enumerated  in  a  more 
concife  manner,  as  particularly  merit  their  attention, 

1.  I  have  already  in  ftrong  terms  pointed  out  the 
propriety  of  an  abfolute  certainty  being  attained,  of 
a  ftone  exifting  in  the  bladder,  before  the  operation 
of  lithotomy  is  propofed  :  and  I  have  endeavoured  to 
fhow,  that  no  fymptoms,  hov.ever  ftrongly  marked, 
afford  fufficient  evidence  of  the  prefence  of  calculus  ; 
the  operation  of  founding,  or  touching  the  ftone  with 
a  ftaff,  being  the  only  certain  means  we  have  of  judg- 
ing of  its  exiftence. 

2.  Before  proceeding  to  the  operation,  a  confider- 
able  quantity  of  urine  fliould  be  allowed  to  collect  in 
the  bladder ;  the  reftum  fliould  be  emptied  by  an  in- 
jection, and  the  buttocks  fliould  be  raifed  above  the 
reft  of  the  body  :  the  external  incifion  fliould  be  more 
extenfive  than  is  commonly  advifed.  In  full  grown 
adults,  inftead  of  the.ufual  length  of  an  inch  and  half, 
or  two  inches,  it  fliould  be  at  leaft  three  inches  and  a 
half  long  ;  care  being  taken  to  commence  the  cut  at 
the  inferior  edge  of  the  pubes,  and  to  continue  it  in 
an  oblique  diredion,  till  it  has  pafled  the  anus,  at  an 
equal  diftance  between  the  end  of  the  reftum  and  the 
tuberofity  of  the  ifchium. 

3.  As  the  chief  refiftance  to  the  extraction  of  the 
ftone,  proceeds  moft  commonly  from  the  mufcles 
covering  the  urethra,  thefe  ought  to  be  freely  divided  : 
no  danger  can  enfue  from  this,  and  much  advantage 
is  derived  from  it. 

4.  But,  although  a  free  divifion  of  the  mufcles  is 
of  much  importance,  there  is  no  neceflity  for  cutting 


Sea.  VIL  Of  the  Stone,  213 

fo  much  of  the  urethra  as  is  commonly  done  :  it  does 
not  facilitate  the  extraftion  of  the  ftone,  and  it  makes 
the  operation  more  hazardous  than  v  hen  the  mem- 
branous part  of  it  only  is  divided.  The  incifion  be- 
ing carried  through  the  teguments  and  mufcles,  fo  as 
to  leave  the  ftaff  covered  by  the  urethra  only,  the  op- 
erator fhould  infert  the  index  and  middle  finger  of  his 
left  hand  into  the  bottom  of  the  wound,  by  which 
means  the  redum  is  completely  protefted ;  and  this 
being  done,  an  opening  fliould  be  made  in  the  urethra 
with  the  point  of  the  fcalpel,  very  near  to  the  prollate 
gland,  from  whence  the  incifion  fhould  be  extended 
upwards  to  the  bulb,  but  no  farther.  This,  I  may  re- 
mark, fhould  be  done  by  one  flroke  of  the  knife,  and 
Jiot  by  repeated  incifions,  as  is  commonly  done ;  for 
iby  this  means  a  rugged  unequal  wound  is  produced. 
In  the  firft  part  of  the  operation,  the  edge  of  the  knife 
fhould  be  applied  in  fuch  a  manner  as  to  cut  from 
above  downwards,  as  in  this  manner  the  incifion  is 
accomplifhed  both  with  eafe  and  fafety ;  but  in  divid- 
ing the  urethra,  the  back  of  the  knife  ought  to  be 
turned  down,  while  the  edge  of  it  penetrates  the  ure- 
thra, and  runs  along  the  fulcus  of  the  flaff.  In  this 
manner  we  cannot  polfibly  hurt  the  redum ;  which  is 
too  frequently  done  in  the  ufual  method  of  perform- 
ing this  part  of  the  operation. 

5.  We  have  now  to  divide  the  proflate  gland,  with 
a  fmall  portion  of  the  neck  of  the  bladder.  This,  I 
have  obferved,  may  be  done  with  eafe  and  fafety, 
with  the  fcalpel  alone,  by  a  good  anatomift,  accuftom- 
ed  to  operate  and  whofe  hand  is  perfedly  fteady  ;  but 
as  the  proflate  gland  mufl  be  divided  in  fuch  a  direc- 
tion as  to  avoid  the  rectum,  with  which  it  is  conned- 
ed  behind,  and  likewife  the  excretory  dufts  of  the  ve- 
ficula;  feminales  which  terminate  here,  much  accura- 
cy is  required  to  get  it  accomplifhed,  and  it  can  only 
be  done  with  fafety  to  thefe  parts  by  a  lateral  cut 
through  this  gland.     A  very  fmall  variation  in  the 


214  Of  the  Stone.  Chap.  XXIX. 

direction  of  the  fcalpel,  might  be  produclive  of  much 
danger  ;  and  few  praditiontrs  being  pofl'efl'ed  of  fuch 
equal  fleadinefs  as  the  certain  prevention  of  this  re- 
quires, a  knife  conftrudted  in  fuch  a  manner  as  to 
protect  the  rectum,  at  the  fame  time  that  it  divides 
the  proftate  gland  properly,  ought  certainly  to  be  pre^ 
ferred.  The  gorget  of  Mr.  Hawkins  is  polfefled  of 
all  thefe  advantages ;  but  I  have  likewife  fhown,  that 
it  is  attended  with  fome  difadvantages.  Thefe,  how- 
ever, are  obviated  by  the  cutting  direftor  that  I  have 
defcribed,  as  well  as  by  the  gorget,  Plate  LXXI.  fig, 
1.  and  2.  which  make  a  more  clean  and  ample  cut 
than  the  common  gorget,  at  the  fame  time  that  they 
do  not  tear  the  urethra,  as  is  done  by  the  gorget  of 
Mr.  Hawkins,  from  its  expanding  too  much  behind. 

6.  After  the  ftone  is  laid  hold  of  with  the  forcepSj^ 
it  Ihould  be  extracted  flowly  ;  not  by  a  rotatory  mo- 
tion, or  by  prefTure  applied  equally  in  ajl  directions  ; 
but  by  endeavouring  to  ftretch  the  parts  along  the 
courfe  of  the  wound,  in  a  line  diredly  between  the 
anus  and  tuberofity  of  the  ifchium.  Moderate  lateral 
preffure  may  likewife  have  fome  influence ;  but  no 
force  fhould  ever  be  applied  towards  the  upper  part 
of  the  wound  ;  for  nothing  can  be  gained  by  doing 
fo,  and  it  muff  always  do  harm,  by  preffing  the  ure- 
thra againft  the  pubes.  When,  in  the  courfe  of  ex- 
traction, it  is  found,  that  the  paflage  of  the  ftone  is 
impeded  by  fome  of  the  mufcles  not  being  freely  di- 
vided, this  ought  ftill  to  be  done,  by  the  operator 
keeping  the  ftone  firm  in  the  forceps  with  one  hand, 
while  with  a  fcalpel  in  the  other,  he  cuts  what  is  ne- 
ceflary  ;  or,  the  forceps  may  be  held  by  an  affiftant, 
while  this  additional  cut  is  going  on. 

7.  The  ftone  being  extradted,  foft  dreflings  fhould 
be  applied  to  the  wound  ;  and  the  patient  fhould  be 
laid  in  bed,  with  his  head  and  upper  part  of  his  body 
raifed  higher  than  the  pelvis,  fo  that  any  blood  pour- 
ed out  from  the  wound,  may  be  freely  difcharged,  in* 


Sea.  VIII.  Of  the  Stone,  2 1  $ 

(lead  of  lodging  In  the  bladder,  which  otherwife  It 
might  do. 

Having  thus  enumerated  fuch  points  in  this  opera- 
tion as  particularly  merit  attention,  I  (hall  now  pro- 
ceed to  confider  the  operation  of  nephrotomy. 


SECTION     VIII. 
Of  Nepbrotoniy, 

WHEN  flones  are  impafled  In  the  kidneys,  fo 
that  they  cannot  pafs  off  with  the  urine,  they 
give  rife  to  a  train  of  very  diftrefsful  fymptoms,  which 
at  laft  almofl:  conftantly  terminate  in  the  death  of  the 
patient. 

The  feverity  of  the  pain  is  frequently  indeed  fo  great, 
as  to  have  induced  practitioners  to  fuggcft  an  operation 
for  extracting  the  {tones.  This  conlifts  in  a  cut  made 
through  the  common  teguments  and  mufcles,  imme- 
diately above  the  kidney,  with  an  opening  into  the 
kidney  itfelf,  of  a  fufficient  fize  to  afford  a  free  paffage 
for  gi  flone  of  an  ordinary  fize. 

But  we  are  to  remember,  that,  however  marked  the 
fymptoms  of  ftone  in  the  kidney  may  appear  to  be, 
that  it  is  impoffible  to  judge  of  it  with  precifion.  We 
know  that  ftone  in  the  kidney  occafions  pain  in  the 
region  of  the  kidney,  together  with  ficknefs  and  vom- 
iting, and  a  difcharge  of  urine,  fometimes  mixed  with 
blood,  at  other  times  with  mucus,  and  in  fome  inftan- 
ces  with  purulent  matter.  We  alfo  know,  however, 
that  the  fame  fymptoms  are  not  unfrequently  induced 
by  other  caufes,  particularly  by  inflammation  and  con- 
fequent  fuppuration  of  the  kidney.  Many  inftances, 
indeed,  have  occurred  of  the  moft:  violent  nephritic 
fymptoms  fubfifting  for  a  great  length  of  time,  where 
ftones  were  fufpeded  as  the  caufe  ;  but  where  the  kid- 
ney has  been  found,  on  diffedion,  to  be  completely 


5 1 6  Of  the  Stone,  Chap.  XXIX. 

fuppurated,  and  as  it  were  entirely  difiblved,  a  quan- 
tity of  purulent  matter  being  all  that  it  contained  ; 
feveral  cafes  of  which  have  fallen  within  my  own  ob- 
fervation. 

Even  in  calculus  of  the  bladder,  a  difeafe  lefs  am- 
biguous than  nephritis  calculofa,  the  fymptoms  are 
never  fo  diftincl  and  cbarafteriftic  as  to  render  the  op- 
eration of  lithoton-y  advifable,  if  a  ft  one  be  not  dif- 
covered  by  the  found.  But  in  difeafes  of  the  kidney 
fufpeclcd  to  proceed  from  flone,  we  are  deprived  of 
this  means  of  diflindion  ;  fo  that  it  might  not  unfre- 
quently  happen,  that,  after  laying  the  kidney  open,  no 
ftone  would  be  found.  This  is,  therefore,  a  very  im- 
portant objedtion  to  the  operation  in  queftion. 

But  it  is  to  be  farther  obferved,  that  the  kidneys  lie 
at  a  great  depth  :  although  not  entirely  covered  by 
the  inferior  falfe  ribs,  yet  that  thefe  ribs  proje6t  fo 
much  over  them,  as  to  itand  much  in  the  way  of  an 
operation  ;  and  that,  in  corpulent  people,  the  kidneys 
are  fcarcely  acceflible. 

Hence,  it  is  impoflible  t(3  make  an  opening  into  the 
kidney  with  fo  much  accuracy  and  precifion,  as  the 
near  Contiguity  of  the  neighbouring  large  blood  vef- 
fels  would  require  ;  and  whoever  attempts  the  opera, 
tion  of  nephrotomy,  even  on  the  dead  body,  will  find 
it  difficult,  or  perhaps  impoffible,  to  cut  into  the  pel- 
vis of  the  kidney,  without  opening  fome  of  the  large 
blood  veflels  that  belong  to  it :  the  great  and  imme- 
diate danger  from  fuch  an  occurrence,  is  too  obvious 
to  require  to  be  farther  mentioned. 

When,  indeed,  the  inflammation  induced  by  a  ftone 
in  the  kidney,  terminates  in  an  abfcefs,  and  when  the 
matter  thus  collecled  forms  a  tumor  in  which  a  fluc^ 
tuation  is  diflinguifhed,  little  or  no  danger  can  enfue 
from  laying  it  open  :  and  in  fuch  an  event,  the  ftone 
that  produced  the  tumor  will  either  be  difcharged 
along  with  the  matter ;  or  it  may,  if  it  can  be  lai4 
hold  of,  be  afterwards  taken  out  with  fafety^ 


Sea.  IX.  Of  the  Stone.  217 

The  ftone  being  thus  taken  out,  the  opening  through 
which  it  paffcd,  if  the  patient  recovers,  will  either  heal 
by  the  ufual  means  employed  for  abfcefles  in  other 
parts  ;  or  the  mod  unfavourable  termination  that  can 
probably  happen,  will  be  a  fiftulous  fore, through  which 
a  mixture  of  pus  and  urine  will  continue  to  be  dif- 
charged. 

Upon  the  whole,  we  may  therefore  conclude,  that 
when  not  direded  by  the  appearance  of  a  tumor  to 
the  part  that  ought  to  be  opened,  the  uncertainty  of 
the  ground  upon  which  we  proceed  when  we  under- 
take this  operation  ;  the  difficulty  of  performing  it ; 
and  the  very  imminent  danger  that  attends  it,  will 
more  than  counterbalance  any  advantage  that  can  be 
derived  from  it ;  fo  that  the  operation  of  nephrotomy 
will  never  probably  be  received  into  general  pradice, 
however  much  it  may  be  recommended  by  fome,  who, 
in  order  to  raife  a  reputation  which  they  might  not 
otherwife  obtain,  will  fometimes  ftcp  forward  and  pro-" 
pofe  with  confidence  what  no  pradlitioner  of  character 
would  think  right  to  attempt.* 


SECTION     IX. 
Of  Stones  in  the  Urethra. 

PATIENTS  liable  to  calculous  complaints  frequent- 
ly pafs  fmall  ftones  with  their  urine.  When 
thefe  ftones  are  fmooth  and  not  very  large,  they  ufu- 
ally  come  off  with  little  difficulty  ;  and  in  fome  cafes 
flones  even  of  a  confiderable  fize  are  paffed  without 
exciting  much  pain.     But  when  an  angular  or  rough 

*  For  further  information  on  the  fub'ieifl  of  nephrotomy,  fee  Rofletut 
de  Partu  C.-vfarco,  cap.  vii.  fcift.  4.  Philofophical  TranfaAions  for  the  year 
1696.  Schcnklus  Obfcrvat.  Med.  lib.  iii.  Juncker's  Confpetfl.  Chirurg.  tab. 
93.  Edinburgh  Medical  Eflays.  Memoires  de  I'Academie  Royalc  de 
tUirurgie  dc  Paris.    And  Mcry's  Obfervativni  fur  la  Maniere  de  Tailler, 


2i8  Of  the  Stone.  Chap.  XXIX. 

ftone  is  pufhed  into  ihc  urethra,  if  not  fo  fmall  as  to 
pals  otF  with  the  hrll  flow  of  urine,  it  never  fails  to 
create  a  great  deal  of  diflrefs. 

Pain  is  the  firll  fyniptom  produced  by  a  ftone  lodg- 
ed in  the  urethra  ;  and  to  this  fucceeds  inflammation, 
tumefaction  of  the  parts,  and  always  a  partial  and  fre- 
quently a  total  fuppreiTion  of  urine.  In  fome  inftan- 
ces,  when  a  ftone  in  this  fituation  is  long  neglected, 
this  fuppreflion  and  confequent  tumefaction  terminate 
in  a  rupture  of  the  ure'dira  ;  in  confequence  of  which, 
the  urine  efcapes  into  the  contiguous  cellular  fubftance, 
and  very  troublefome  fwellings  arife  not  only  in  the 
body  of  the  penis,  but  frequently  in  the  fcrotum,  and 
through  the  whole  courfe  of  the  perina^um. 

The  treatment  fuited  to  fuch  tumors  will  be  point- 
ed out  when  we  co\m  to  treat  of  fiftulous  fores  in 
thef^  parts  ;  fo  th^t  I  fliall  now  only  relate  the  eafieft 
and  moft  efl.'eclual  means  of  extratting  ftones  from  the 
urethra. 

When  a  ftone  has  been  long  fixed  at  one  particular 
part  without  yielding  in  any  degree,  and  when  the 
pain  and  inflammation  that  it  excites  are  confiderable, 
it  ought  to  be  cut  out  in  the  manner  I  ftiall  hereafter 
advil'e  j  but  on  firft  paffmg  down  from  the  bladder  to 
the  urethra,  we  frequently  fucceed  by  more  gentle 
means. 

Whether  or  not  the  urethra  itfelf  is  poflfefiTed  of  any 
contractile  power,  is  a  point  not  to  be  eafily  afcertain- 
ed  ;  but  the  mufcles  with  which  it  is  immediately  con- 
nected, are,  in  common  with  other  mufcular  parts,  fub- 
jed  to  the  influence  of  ftimuli ;  and  as  nothing  with 
which  we  are  acquainted,  can  be  fuppofed  to  give  a 
more  powerful  ftimulous  to  a  fenfible  part  than  the 
irritation  of  a  rough  or  angular  ftone,  fo  we  may  fair- 
ly conclude,  that  when  once  a  ftone  is  impacted  in  the 
urethra,  its  farther  paflage  along  that  canal  will  be 
impeded  by  a  fpafmodic  contraction  of  the  contiguous 
mufcles.  One  very  important  indication,  therefore, 
in  the  treatment  of  this  malady,  is,  the  removal  of 


Sea.  IX.  Of  the  Stone,  21^ 

fpafm  ;  and  when  we  keep  this  idea  in  view,  and  con- 
tinue to  perfifl  in  the  ufe  of  proper  remedies,  we  fel- 
doni  fail  to  bring  oif  fuch  ftones  as  have  been  lodged 
in  the  urethra,  without  the  aid  of  any  chirurgical  op- 
eration. But,  inftead  of  the  application  of  means  cal- 
culated for  the  removal  of  fpafm,  the  ordhiary  prac- 
tice of  furgeons  is  the  direct  reverfe,  and  is  therefore 
apt  to  produce  a  very  oppofite  effeft. 

An  attempt  is  commonly  made  to  pufh  the  flone 
forward  at  once  with  the  fingers.  It  is  obvious,  how- 
ever, that  until  the  fpafm  by  which  the  obftrudion  is 
partly  produced  is  removed,  every  trial  of  this  kind 
will  rather  tend  to  incrcafe  the  complaint.  For  this 
reafon,  therefore,  no  preflTure  fhould  be  employed  till 
the  moft  elfedual  means  have  been  ufed  for  removing 
the  fpafm  produced  by  the  (lone.  With  this  view, 
the  patient,  if  he  is  plethoric,  ought  to  lofe  a  confid- 
erable  quantity  of  blood  by  the  lancet ;  or,  if  he  is 
thin  and  emaciated,  a  proportional  quantity  fliould  be 
difcharged  by  leeches,  diredly  from  the  pained  part, 
A  quantity  of  warm  oil  (liould  be  repeatedly  injected 
into  the  urethra,  in  order  to  lubricate  the  paifage. 
The  patient  fliould  be  immerfed  in  a  warm  bath  ;  and 
a  full  dofe  of  laudanum  (hould  be  given  about  an  hour 
bef(M"e  going  into  the  bath. 

Together  with  thefe  remedies,  a  plentiful  ufe  of  di- 
uretics, and  diluent  drinks,  is  commonly  prefcribed  ; 
but,  inflead  of  proving  ufeful,  they  almoll  conilantly 
do  harm.  For,  when  the  urine  ruflies  out  with  vio- 
lence, if  it  does  not  carry  the  flone  freely  out  of  the 
urethra,  it  tends  to  fix  it  more  firmly  than  before  ;. 
and  the  pain  thus  produced,  w'll  always  increafe  the 
inflammation,  tenfion  and  fpafm  of  the  parts  alfefted  : 
fo  that  whatever  has  much  effect  in  increafing  thq 
quantity  of  urine,  fhould  be  carefully  avoided. 

A  proper  quantity  of  blood  having  been  difcharg- 
ed ;  the  patient  having  remained  for  a  fufficient  length 
of  time  in  the  warm  bath  ;  and  the  opiate  having  be^ 
gun  to  operate  j  the  parts  will  thus  be  as  completely 


mo  Of  the  Stone,  Chap.  XXIX. 

relaxed  as  poflible  ;  and  this  is  the  period  when  fome 
attempt  Ihould  be  made  for  extradling  the  ftone.  Va- 
rious inftruments  have  been  contrived  for  this  pur- 
pofe,  particularly  long  fmall  pliers  or  forceps,  conceal- 
ed in  a  canula  of  a  fize  correfponding  to  that  of  the 
urethra  ;  but  as  none  of  thefe  have  ever  proved  ufe- 
ful,  and  as  they  often  do  much  harm,  by  tending  to 
increafe  the  irritation  in  the  urethra,  I  do  not  think  it 
neceflary  to  delineate  any  of  them. 

Inftead  of  ufnig  thefe  inftruments,  the  furgeon 
fhould  at  firft  endeavour  by  gentle  prelfure  to  pufii  the 
ftone  forward  along  the  urethra,  and  by  continuing  to 
move  it  eafily  in  different  directions,  and  perfevering 
for  a  confiderable  time,  we  often  fucceed  in  bringing 
it  off,  when  otherwife  it  muft  have  been  cut  out. 

It  frequently  happens,  however,  that  ftones  of  fuch 
a  fize  and  figure  get  into  the  urethra,  as  cannot  by 
any  means  be  made  to  pafs  off.  When  a  ftone,  thus 
fixed  in  the  paflage,  is  of  fuch  a  form  as  to  admit  of 
the  urine  being  difcharged,  a  patient,  rather  than  fub- 
mit  to  an  operation,  will  fometimes  allow  it  to  remain  ; 
by  which  the  ftone,  in  a  fhort  time,  commonly  obtains 
an  increafe  of  fize  by  a  depofition  of  earthy  matter 
from  the  uripe :  of  this  I  have  met  with  various  in- 
ftances,  in  which  the  ftones  became  very  large,  and 
in  which  the  urethra  was  fo  much  dilated  as  to  form 
an  extenfive  pouch  or  cavity  correfponding  to  the  fize- 
and  figure  of  the  ftone.  But  when  the  ftone,  inftead 
of  allowing  any  of  the  urine  to  pafs,  fills  up  the  ure- 
thra entirely,  it  becomes  neceffary  to  remove  it  by  an 
operation,  as  foon  as  the  means  that  I  have  advifed 
have  been  found  to  prove  of  no  avail. 

This  operation  confifts  in  cutting  diredly  upon  the 
flone,  and  extracling  it  either  with  a  fcoop,  or  with 
fmall  forceps  ;  but  the  methods  of  effeding  this  ought 
to  vary  according  to  the  part  of  the  urethra  in  which 
the  ftone  is  fixed.  When  a  ftone  is  fituated  near  to 
the  beginning  of  the  urethra,  and  contiguous  to  the 
bladder,  it  has  been  advifed  to  pufh  it  again  into  the 


Sed:.  IX.  Of  the  Stone*  22 1 

bladder  by  means  of  a  ftaff :  but  as  it  might  there 
probably  acquire  a  larger  fize,  and  would  confequent- 
ly  render  the  patient  liable  to  all  the  diftrefs  and  haz- 
ard arifmg  from  a  ftone  in  the  bladder,  this  is  a  prac- 
tice by  no  means  to  be  admitted,  as  the  ftone  may  be 
extraded  with  much  more  eafe  from  any  part  of  the 
urethra,  and  with  much  lefs  hazard  to  the  patient, 
than  is  always  incurred  by  the  more  formidable  oper- 
ation of  cutting  into  the  bladder. 

When,  therefore,  an  operation  is  neceflary  for  ex- 
tracting a  flone  fixed  in  the  urethra  near  the  neck  of 
the  bladder,  the  method  of  performing  it  is  this : 

The  patient  fliould  be  laid  upon  a  table,  and  fecur- 
ed  in  the  manner  I  have  direded  for  lithotomy  :  and 
an  affiftant  fufpending  the  fcrotum  and  penis,  the  fur- 
geon,  after  oiling  the  firft  and  fecond  fingers  of  his 
left  hand,  fliould  introduce  them  into  the  anus,  and 
by  means  of  them  ought  to  prefs  firmly  upon  the  parts 
immediately  behind  the  flone  ;  which  will  not  only 
enable  him  to  lay  it  bare  with  more  eafe,  but  will  be 
the  furefl  method  of  preventing  it  from  being  puflied 
into  the  bladder  by  the  neceffary  preffure  of  the  knife. 
This  being  done,  an  incifion  fliould  be  made  through 
the  common  teguments  and  urethra,  fo  as  to  lay  the 
ftone  completely  bare  ;  which  may  now  be  either  turn- 
ed out  by  a  due  degree  of  preffure  applied  with  the 
fmgers  in  the  re6tum  ;  or,  if  this  be  not  fufficient,  it 
may  be  taken  out  either  with  a  fcoop,  or  with  fmall 
forceps. 

The  after  treatment  is  the  fame  here  as  I  have  ad- 
vifed  in  the  operation  of  lithotomy. 

When,  again,  a  ftone  has  paffed  farther  on  in  the 
urethra,  in  order  to  extract  it  the  fkin  fliould  be  drawn 
as  much  as  pofTible  pafl  it,  either  in  a  backward  or 
forward  direction ;  and  the  flone  being  now  fecured 
in  its  fituation  by  preffure,  a  longitudinal  cut  is  to  be 
made  upon  it,  directly  through  the  fkin,  cellular  fub- 
ftance,  and  urethra,  of  a  fufficient  fize  to  admit  of  its 
being  extracted,  either  with  the  fcoop  or  forceps.  The 


222  Of  the  Stone.  Chap.  XXIX^ 

edges  of  the  wound  are  now  to  be  completely  cleared 
of  fabulous  particles,  and  the  fkin  allowed  to  regain 
its  natural  fituation  ;  by  which  means,  if  the  opera- 
tion has  been  properly  done,  the  wound  in  the  ure- 
thra will  be  entirely  covered  with  fkin  that  has  not 
been  injured  ;  a  circumftance  that  tends  to  render  the 
operation  much  lefs  formidable  than  it  otherwife  would 
be ;  for  the  wound  in  the  urethra  is  thus  fo  well  pro- 
tected, that  it  commonly  heals  by  the  firft  intention. 

It  fometimes  indeed  happens,  when  the  operation  is 
done  in  this  manner,  that  in  voiding  urine,  part  of  it 
efcapes  at  the  wound,  and  infmuates  into  the  contigu- 
ous cellular  fubftance.  This,  however,  is  a  rare  oc- 
currence, and  the  inconveniencies  that  arife  from  it  are 
cafily  obviated,  by  laying  open  any  colledion  of  urine 
that  takes  place  during  the  cure. 

When  a  ftone  fixes  near  to  the  point  of  the  yard,  in 
that  part  of  the  urethra  running  through  the  glans  ; 
if  it  is  fo  near  as  to  be  fcen,  it  may  frequently  be  tak- 
en out  with  fmall  diifecling  forceps  :  and  in  order  to 
facilitate  the  extraction,  when  it  cannot  be  otherwife 
done,  the  end  of  the  urethra  may  be  dilated  with  the 
point  of  a  biftoury :  but  when  this  fails  of  fuccefs,  an 
incifion  muft  be  made  upon  the  ftone  in  the  manner 
I  have  advifed  where  the  urethra  is  covered  vi^ith  fkin. 
Soft  drefhngs  fliould  be  applied  to  the  wound ;  and 
when  the  cure  is  nearly  completed,  a  hollow  bougie, 
a  fhort  filver  tube,  or  a  catheter  of  elaftic  gum,  fhould 
be  pafled  into  the  urethra,  in  order  to  preferve  it  of  a 
proper  fize. 

The  moft  perplexing  fituation  in  which  a  ftone  can 
be  fixed  in  the  urethra,  is  juft  behind  the  fcrotum  ; 
f(5r  if  the  ftone  is  either  forced  into  the  fcrotum,  or  if 
it  becomes  ncceftary  to  make  an  opening  into  it  with 
a  fcalpel,  the  urine  is  apt  to  collect  in  it,  from  which 
a  great  deal  of  diftrefs  never  fails  to  enfue. 

In  order,  therefore,  to  obviate  this  inconvenience, 
as  fuon  as  a  ftone  is  difcovered  in  this  fituation,  we 


ii 


S^a.  IX.  Of  the  Sionc.  243 

fhould  endeavour,  with  all  poffible  attention,  either  to 
get  it  carried  farther  along  the  urethra,  or,  if  this  can- 
not be  done,  to  pulh  it  back  into  the  perinjeum  with 
a  (laif :  but  when  this  is  found  to  be  impra6licable, 
and  that  the  ftone  mull  be  extraded,  an  incifion 
fliould  be  mide  in  the  urethra,  by  beginning  the  cut 
at  the  under  part  of  the  fcrotum,  immediately  to  one 
fide  of  the  feptum,  and  proceeding  upwards  till  the 
ftone  is  diflinftly  felt,  when  it  mult  be  laid  bare  and 
taken  out  in  the  manner  I  have»already  advifed. 

By  making  the  incifion  from  below  upwards,  any 
urine  that  efcapes  from  the  urethra  finds  a  free  paf- 
fage  J  and  if  the  opening  is  fufficiently  large,  the  ftone 
may  in  this  manner  be  extracted  eafily :  during  the 
operation,  the  teftes  fhould  be  as  much  protected  as 
poflible  :  and  on  the  ftone  being  removed,  the  drcflings 
fliould  be  applied  in  fuch  a  manner,  that  the  fore  may 
heal  from  the  bottom  ;  for  this  being  neglected,  and 
the  teguments  allowed  to  heal  before  every  vacancy 
is  filled  up,  purulent  matter,  and  perhaps  urine,  will 
very  probably  colled,  and  may  thus  give  rife  to  trou- 
blefome  fmufes. 

When  urine  continues  to  be  difcharged  for  any 
length  of  time  at  a  preternatural  opening  of  the  ure- 
thra, whether  the  confequence  of  the  operation  of  li- 
thotomy or  of  any  other  caufe,  if  the  calculous  diathe- 
fis  prevails,  ftones  of  a  large  fize  will  frequently  form 
in  the  cellular  fubftancc  contiguous  to  the  opening. 
I  have  met  with  feveral  inltances  of  this  :  in  fome  the 
ftones  were  fiuall,  and  eafily  taken  out ;  but  in  others, 
where  they  fpread  and  occupied  a  confiderable  por- 
tion of  the  cellular  membrane,  they  were  very  difficult 
to  remove.*  The  treatment  here  confifts  folely  in 
making  a  free  incifion  along  the  courfe  of  the  calcu- 
lous concretions  j  in  turning  them  out,  either  with  a 

•  A  very  remarkable  cafe  of  this  nature  is  recorded  hv  Gooch.  Sed 
Cafts  and  PraClical  Rcuiiiiks  iii  Surgery,  vol.  ii,  p.  Z74,  by  Benjamin 
Oooch. 


224  Of  the  Stone.  Chap.  XXIX. 

fcoop  or  fmall  forceps ;  and  in  drefling  the  wound 
properly,  fo  as  to  induce  a  firm  adhefion  of  the  parts 
beneath,  before  the  teguments  are  permitted  to  heal. 
In  females,  the  urethra  is  fo  fliort,  and  dilates  fo 
readily,  that  fmall  flones  feldom  flop  in  it :  they  are 
moft  commonly  carried  off  by  the  flow  of  urine  that 
brings  them  into  it ;  but  when  they  happen  to  fix  in 
it,  they  are  eafily  turned  out,  merely  by  infinuating 
the  end  of  a  blunt  probe  behind  them,  and  then  pul- 
ling them  forward :  or,  when  this  docs  not  fucceed,  it 
may  always  be  done  with  fafety,  by  laying  open  the 
extremity  of  the  urethra  with  a  fcalpel,  fo  far  as  to 
admit  of  the  introduction  of  fmall  foixeps. 


1 


Chap.  XXX*         Inccnthwice  of  Urine,  I25 


CHAPTER     XXX. 


OF    INCONTINENCE    OF    URINE. 


INCONTINENCE  of  urine  may  arife  from  various 
caufes  ;  but  being  frequently  conneded  with  cal- 
culous complaints,  and  in  fome  inflances  the  confe- 
quence  of  the  operation  of  lithotomy,  I  am  hence  in- 
duced to  fpeak  of  it  here. 

1.  It  may  arife  from  irritation  about  the  neck  of 
the  bladder,  produced  by  the  fri(9:ion  of  ftones  con- 
tained in  it.  Thus  we  know,  that  inability  to  retain 
urine  is  a  frequent  fymptom  of  ftone  in  the  bladder ; 
and  we  cannot  fuppofe  it  to  proceed  from  any  other 
caufe  than  the  conllant  ftimulus  communicated  by  the 
llone  to  the  coats  of  the  bladder.  For,  were  it  always 
produced,  as  has  been  fuppofed,  by  a  total  lofs  of 
power  in  the  fphincter  veficec,  the  difeafe  would  fel- 
dom  or  never  admit  of  a  cure.  But  we  know  well,  that 
incontinence  of  urine,  depending  upon  flone  in  the 
bladder,  is  often  removed  entirely  by  the  operation  of 
lithotomy :  and  we  likewife  know,  that  it  is  often 
much  relieved,  even  when  the  ftone  remains  in  the 
bladder,  by  the  ufe  of  thofe  remedies  that  moft  effec- 
tually remove  irritability ;  particularly  by  a  plentiful 
ufe  of  mucilaginous  drinks,  and  a  free  ufe  of  opiates. 
By  a  continued  ufe  of  thefe  remedies,  indeed,  this  va- 
riety of  the  difeafe  is  commonly  removed  with  more 
certainty  than  by  anv  other  means,  extradion  of  the 
ftone  excepted  ;  which,  when  thefe  fail,  is  to  be  kept 
in  view  as  the  only  refource  upon  which  we  are  to  de- 
pend. 

2.  Incontinence  of  urine  is  a  frequent  effect  of  pal- 
fy ;  and  it  would  appear,  that  the  fphincler  of  the 

Vol.  III.  O 


226  Incontinence  of  Urine.         Chap.  XXX, 

bladder  fometimes  lofes  its  contra£tile  power,  while 
the  natural  tone  of#he  inufcle  termed  detrufor  urinse, 
which  conflitutes  the  chief  part  of  the  body  of  the 
bladder,  remains  entire.  In  this  variety  of  the  difeafe, 
the  obflinacy  of  the  paralytic  affeclion  with  which  the 
conftitution  is  attacked,  commonly  renders  fruitlefs 
every  attempt  to  remove  it.  But  the  moft  obvious 
remedies  to  be  employed  for  it,  are,  tonics,  particular- 
ly Peruvian  bark,  chalybeates,  and  efpecially  the  cold 
bath  general  and  local.  The  local  application  of  cold 
to  the  perinasum  has  frequently  a  powerful  influence : 
cloths  wet  with  vinegar  and  cold  water,  or  with  a 
ftrong  folution  of  faccharum  faturni  in  vinegar,  prove 
fometimes '  ufeful ;  but  the  moft  efFedlual  method  of 
applying  cold,  is  by  dafhing  water  upon  the  loins,  pe- 
rinasum  and  fundament. 

3.  Incontinence  of  urine  is  not  an  unfrequent  efFe£t 
of  laceration  in  the  operation  of  lithotomy  in  male 
fubjeds ;  and  in  the  fame  operation,  and  by  violence 
done  to  the  parts  in  delivery,  m.  females.  It  ought, 
however,  to  be  remembered,  when  in  the  lateral  ope- 
ration much  laceration  is  produced,  that  in  general  it 
proceeds  from  the  mufcles  not  having'been  divided 
with  fufHcient  freedom  by  the  knife ;  and  according- 
ly, except  in  cafes  of  large  flones,  incontinence  of 
urine  feldom  fucceeds  to  this  operation  when  proper- 
ly performed. 

As  the  difeafe  in  this  cafe  depends  upon  nearly  the 
fame  caufe  as  that  which  I  mentioned  laft,  namely,  on 
a  lofs  of  power  in  the  retaining  parts,  the  fame  reme- 
dies are  proper ;  and  by  due  perfeverance,  particular- 
ly in  the  ufe  of  cold  bathing,  many  are  at  laft  very 
completely  cured  of  this  variety  of  the  difeafe.  But 
it  fi-equently  happens,  in  all  the  varieties  of  the  dif- 
eafe, that  no  relief  is  obtained  from  any  remedy  what- 
ever ;  in  which  cafe,  it  becomes  an  objedl  of  import- 
ance to  prevent  the  urine  from  incommoding  the  pa- 
tient, which  never  fails  to  happen,  if  means  are  not 
employed  to  prevent  it. 


A 


Chap.  XXX.        Incontinetice  of  Urine,  iij 

When  it  proceeds  from  either  of  the  la  ft  mention* 
ed  caufes,  namely,  from  a  paralyfis  of  the  iphincter  of 
the  bladder,  or  from  laceration,  comprellion  of  the 
urethra  anfwers  the  purpofe ;  as  the  preffure  can  be 
fo  modified  as  to  be  applied  and  removed  at  pleafure* 
Nuck  invented  the  firll  inftrument  for  this  purpoie  of 
which  any  defcription  is  given.  The  jugum,  or  yoke, 
as  it  is  termed,  Plate  LXXVII.  fig.  i.  is  an  improve^ 
mcnt  upon  this  ;  and,  when  properly  fitted,  it  anfwers 
the  purpofe  exceedingly  well.  When  lined  with  quilt* 
ed  filk  or  velvet,  it  fits  eafily  on  the  penis,  and  by 
means  of  the  fcrew,  the  preffure  can  be  made  fuffi- 
ciently  tight.  For  women  another  invention  is  necef- 
.  fary,  as  the  preffure  muft  be  applied  through  the  va- 
gina. Peffaries  of  refma  elaftica,  and  of  fponge,  have 
been  propofed  for  it,  but  thofe  of  ivory  or  lignum 
vitse  anfwer  better ;  in  Plates  LXXIV.  and  LXVl.  are 
reprefented  peffaries  of  difi'erent  kinds. 

Peffaries  fhould  all  be  finely  polifhed,  and  dipped 
in  oil  immediately  before  being  introduced.  After 
b-ing  paffed  into  the  vagina,  the  peffary  fliould  be 
placed  directly  acrofs,  fo  as  to  prefs  with  as  much  ef- 
fect as  poffible  againft  the  urethra. 

This  method  of  obviating  the  inconveniencies  arifmg 
from  incontinence  of  urine,  by  preffure,  is  not,  how- 
ever, applicable  when  the  difeafe  proceeds  from  irri- 
tation about  the  neck  of  the  bladder ;  for  the  conti- 
nual defirc  to  pafs  water,  with  which  patients  in  fuch 
circumflances  are  tormented,  renders  every  attempt 
to  fupprefs  a  complete  difcharge  of  it  totally  inadmif- 
fible.  It  is  therefore  a  point  of  the  firft  importance 
to  diftinguifli  between  the  different  caufes  of  this  fymp- 
tom  ;  for  it  is  obvious  that  a  remedy  that  may  be  well 
calculated  for  one  variety  of  the  difeafe,  may  prove 
highly  prejudicial  in  others. 

Whenever  it  is  found  that  preffure  upon  the  ure- 
thra is  improper,  or  that  it  does  not  anfwer,  relief  may 
commonly  be  obtained  from  a  machine  properly  fit- 
0^2 


228  Tncontincnce  of  Urine.         Chap.  XXX. 

ted  to  fei*ve  as  a  refervoir  for  the  urine.  The  inftru- 
ments  formerly  referred  to,  reprefented  in  Plates  LV. 
and  LXXVII.  have  been  often  ufed,  and  commonly 
with  much  advantage.  They  ftiould  be  made  fo  as  to 
apply  as  clofely  as  poflible  to  the  parts  on  which  they 
reft  ;  and  when  properly  fixed  to  a  circular  bandage 
round  the  body,  they  remain  fufficiently  firm,  and  at 
the  fame  time  admit  of  every  necefl'ary  change  of  pof- 
ture  in  ordinary  exertions  of  the  body.  The  laft  of 
thefe  inftruments,  namely,  the  one  delineated  in  Plate 
LXXVII.  fig.  2.  proves  ufeful  only  in  men  ;  but  the 
other,  Plate  LV.  fig.  2.  may  be  employed  for  women 
alfo. 


Chap.  XXXI.        Suppreffton  of  Urine,  229 


CHAPTER    XXXI. 


OF    SUPPRESSION    OF    URINE. 


THE  fubjeft  of  the  preceding  chapter,  namely,  ia- 
continence  of  urine,  proves  always  troublefome 
and  inconvenient ;  but  the  difeafe  that  we  are  now  to 
confider,  proves  in  every  inftance,  very  alarming,  and 
often  ends  in  the  death  of  the  patient.* 

A  fuppreffion  of  urine  may  be  the  effeft  of  various 
caufes,  and  in  the  method  of  cure  a  nice  difcrimina- 
tion  of  thefe  is  neceflfary. 

I.  In  the  preceding  chapter  we  have  feen,  that  in- 
■continence  of  urine  is  often  produced  by  the  fphinder 
of  the  bladder  becoming  paralytic,  while  the  detrufor 
urina:  ftill  retains  its  power  of  contradion.  In  like 
manner,  a  fupprellion  of  urine  frequently  occurs  in 
palfy,  and  feems  to  proceed  from  lols  of  power  in  the 
body  of  the  bladder,  while  the  fphinder  {till  preferves 
its  ufual  power  of  retention. 

Although  this  variety  of  the  difeafe  is  often  con- 
nected with  palfy  of  all  the  under  part  of  the  body, 
yet  it  is  frequently  induced  by  the  pernicious  cuftom 
of  remaining  too  long,  efpecially  when  drinking  free- 
ly of  diuretic  liquors,  without  voiding  urine ;  by 
which  the  bladder  is  fometimes  fo  far  over  diftended, 
that  it  lofes  entirely  all  power  of  contraction. 

The  catheter  proves  here  commonly  a  very  certain 
remedy  when  employed  early,  and  it  fhould  always  be 
advifed  as  foon  as  it  is  found  that  the  urine  colleded 


*  It  is  that  variety  of  the  difeafe  to  which  I  alhide,  in  which  the  urine 
is  colleoled  in  the  bladder,  but  which  the  patient  is  unable  to  difcharge. 
When  fupprcfl'ion  takes  place  from  a  morbid  (late  of  the  kidneys,  a  vari- 
ety of  the  difeafe  is  produced,  that  no  cliirurgical  operation  can  relieve 
fo  tliat  it  does  not  fall  to  be  tonlidered  here. 


230  Supprejfioti  of  Urine.        Chap.  XXXL 

in  the  bladder  cannot  be  paiTed.  For  although  the 
ufe  of  this  inftrument  fliould  never  be  advifed  where 
it  can  with  fafety  be  avoided,  yet  as  in  the  circuui- 
ftances  we  are  now  confidering,  delay  never  fails  to 
prove  dangerous,  the  urine  (hould  always  be  drawn  off 
as  foon  as  the  itoppage  excites  irritation.  At  the  com- 
mencement of  the  di'eafe,  it  is  for  the  mod:  part  eafi- 
ly  done  ;  while  long  delay,  by  exciting  fwelling  and 
inflammation  about  the  neck  of  the  bladder,  never  fails 
to  render  it  both  more  difficult  and  more  painful,  and 
in  fome  inflances  even  impoflible  to  pafs  the  catheter. 
The  method  of  paffing  the  catheter,  both  in  male  and 
female  fubjefts,  is  the  fame  with  the  operation  of 
founding  for  the  (lone,  already  defcribed  in  Chapter 
XXIX.Sedionll. 

2.  A  fuppreffion  of  urine  is  frequently  produced  in 
the  laft  months  of  pregnancy,  by  the  preffure  of  the 
uterus  on  the  neck  of  the  bladder.  So  completely  in- 
deed is  the  urine  fometimes  obftrucled  by  this,  that 
not  a  fmgle  drop  can  be  difcharged  but  with  the  aid 
of  a  catheter ;  and  as  this  Inftrument  is  in  females 
commonly  introduced  with  eafe,  it  fliould  always* be 
done  as  foon  as  the  urine  cannot  be  otherwife  avoided. 
Delay  in  ufmg  the  catheter  is  often  the  caufe  of  much 
diftrefs.  In  different  inftances,  the  bladder  has  from 
this  caufe  alone  been  diftended  to  fuch  a  degree  as  to 
lofe  the  power  of  contraction ;  and  in  a  few  cafes,  it 
has  even  burft  entirely  :  we  fliould  not  therefore  hefi- 
tate  to  advife  the  catheter  to  be  employed,  on  finding 
that  the  bladder  is  in  any  degree  diftended  beyond  its 
ufual  fize. 

3.  Tumors  in  the  vagina  and  neighbouring  parts, 
when  they  become  large,  are  apt  to  comprefs  the  ure- 
thra fo  much  as  to  induce  a  total  fuppreffion  of  urine  ; 
and  a  prolapfus  uteri  is  often  attended  with  the  fame 
effea. 

The  method  of  treatment  beft  calculated  for  remov- 
ing a  prolapfus  uteri,  as  likewife  the  means  of  cure 
commonly  employed  in  tumors  in  the  vagina,  will  be 


Chap.  XXXI.        Suppreffion  of  Urine,  23  j 

the  fubje^s  of  different  chapters ;  only  it  miift  be  re- 
membered, that  till  thefe  views  are  accompliflied,  the 
urine  (hould  be  regularly  drawn  off  with  the  catheter, 
whenever  it  is  collected  in  large  quantities. 

The  very  irritable  (late  of  the  parts  about  the  neck 
of  the  bladder  that  often  prevails  in  fuppreffion  of 
urine,  renders  it  neceffary  in  fome  inftances  to  ufe  the 
catheter  often.  Inflead  of  this,  fome  praditioners 
have  advifed  the  common  catheter  to  be  allowed  to  re- 
main in  the  bladder  a  confiderable  time  at  once,  fo  as 
to  admit  of  the  urine  being  difcharged  as  foon  as  it  is 
fecreted :  but  this  is  a  practice  that  ought  not  to  be 
admitted ;  for  the  irritation  arifmg  from  a  long  con- 
tinuance of  a  catheter  in  the  bladder,  commonly  does 
more  harm  than  we  ever  experience  from  a  frequent 
ufe  of  it.  When  it  is  wiflied,  however,  to  allow  a 
catheter  to  remain  in  the  bladder,  either  for  this  pur- 
pcfe,  or  for  wounds  in  the  urethra,  the  hard  filver 
tubes  in  common  ufe  ought  not  to  be  employed  :  thofe 
that  are  prepared  with  refma  elaflica,  anfwers  the  in- 
tention better,  and  I  have  found  by  experience,  that 
they  do  not  diffolve  in  the  urine :  in  one  cafe  a  tube 
of  this  refm  was  kept  in  the  bladder  twenty-two  days 
without  being  hurt  by  the  urine. 

4.  A  ftoppage  to  the  flow  of  urine  is  not  an  unfre- 
quent  effe£l  of  an  enlarged  ftate  of  the  proflate  gland, 
and  of  obftructions  in  the  urethra  in  virulent  gonor- 
rhoea. The  treatment  beft  fuited  to  thefe  affedlions 
will  form  the  fubjed  of  part  of  the  enfuing  chapter. 

Suppreffion  of  urine  induced  by  (tones  impacted  in 
the  urethra,  has  been  already  confidered  in  Sedion 
IX.  of  Chapter  XXIX,  where  the  remedy  was  point- 
ed out. 

5.  But  the  mod  alarming  variety  of  the  difeafe,  is 
that  which  proceeds  from  inflammation  about  the  neck 
of  the  bladder,  inducing  pain  and  fwelling  to  fuch  a 
degree,  as  often  make  it  impoffible  to  pafs  the  cathe* 
ter. 


232  SupprcJJton  of  Urine.        Chap.  XXXI, 

Suppreffion  of  urine  from  this  caufe  is  not  an  un- 
frequent  confequence  of  inflammation  in  gonorrhoea 
proceeding  backwards  along  the  urethra :  it  is  fome^ 
times,  although  not  often,  induced,  by  an  unguarded 
ufe  of  ftimulating  injections  ;  and  as  the  bladder  is 
equally  liable  with  other  parts  of  the  body,  to  the  in- 
fluence of  every  caufe  that  excites  inflammation,  what^ 
ever  excites  inflammation  in  other  parts  will  very  rea- 
dily do  fo  here. 

In  whatever  way  inflammation  may  be  induced,  the 
means  of  cure   fhould   be  nearly  the  fame :    blood 
ihould  be  difcharged  from  the  arm  in  quantities  pro- 
portioned to  the  ftrength  of  the  patient,  and  a  confid- 
erable  number  of  leeches  fhould  be  applied  to  the  pe- 
rinseum  as  near  as  poflible  to  the  feat  of  the  difeafe, 
and  allowed  to  bleed  freely.     Opiates  fhould  be  giv- 
en in  large  dofes ;  injections  of  warm  water  or  r^iilk, 
whether  by   themfelves    or   combined   with  opiates, 
Ihould  be  repeatedly  thrown  into  the  reftum  ;  and  the 
whole  body  fhould  be  immerfed  in  the  warm  bath. 
By  thefe  means,  when  the  inflammation  is  not  violent, 
the  fupprefTion  will  in  fome  inftances  be  removed  be- 
fore any  diflrefsful  fymptoms  take  place.     But  when 
thefe  remedies  do  not  prove  effectual ;  when  the  blad- 
der becomes  painfully  diftended ;  and  when  every  at- 
tempt to  introduce  the  catheter  has  failed,  other  means 
of  relief  fhould  be  employed.     In  fuch  circumilances, 
puncturing  the  bladder  is  the  only  remedy  on  v/hich 
we  can  with  certainty  depend :  being  an  operation  of 
fome  nicety  and  hazard,  arifmg  not  fo  much  from  the 
difficulty  of  doing  it,  as  from  the  confequences  that 
fometimes  refult  from  it,  and  the  flrid  confinement 
that  for  a  confiderable  time  it  entails  upon  the  patient, 
it  ought  never  to  be  advifed  till  the  other  remedies  I 
have  mentioned  have  been  tried  in  vain ;  at  the  fame 
time,  however,  I  think  it  right  again  to  obferve,  that 
it  fhould  never  be  long  delayed  after  our  other  rjieans 
of  relief  have  been  found  to  fail. 


Chap.  XXXI.        Supprefflon  of  Urine.  233 

The  bladder  may  be  pundured  in  various  ways :  it 
may  be  done  a  little  above  the  pubes  :  the  membra- 
nous part  of  the  urethra,  and  proftate  gland  may  be 
cut,  and  an  opening  made  in  the  neck  of  the  bladder. 
An  opening  may  be  made  from  the  perinscum,  direct- 
ly into  the  body  of  the  bladder  ;  and  a  pundure  may 
be  made  in  the  back  part  of  the  bladder  by  paffing  a 
trocar  into  it  from  the  redum.  As  the  method  of 
punduring  the  bladder,  after  dividing  the  membra- 
nous part  of  the  urethra  and  proftate  gland,  is  obvi- 
oufly  more  hazardous  than  any  of  the  others,  it  is  now 
very  defervcdly  laid  afide,  fo  that  it  is  not  neceflary 
to  fpeak  of  it  farther.  We  have,  therefore,  only  to 
confider  the  other  three  modes  of  operating. 

In  puncturing  the  bladder  above  the  pubes,  we  are 
directed  by  authors,  firft  to  make  an  incifion,  two 
inches  in  length,  through  the  common  teguments  and 
mufcles,  and  then  to  perforate  the  bladder  with  a  tro- 
car. But  there  is  no  neceflity  for  this  extenfive  divi- 
fion  of  the  teguments  and  mufcles  ;  for  the  operation 
may  be  done  with  equal  fafety  and  with  lefs  pain  to 
the  patient,  by  pufliing  a  trocar  at  once  through  the 
fkin,  mufcles,  and  bladder  ;  and  it  may  be  entered 
any  Vvhere  from  the  height  of  half  an  inch  to  an  inch 
and  half  above  the  pubes,  and  at  half  an  inch  or  there- 
by on  either  fide  of  the  linea  alba.  Some  advife  the 
trocar  to  be  paffed  obliquely  downwards,  with  a  viev/ 
to  prevent  the  back  part  of  the  bladder  from  being 
hurt  ;  but  we  ad  with  more  fafety,  and  guard  with 
more  certainty  againft  this  injury  to  the  bladder,  by 
making  ufe  of  a  ihort  canula,  and  pafllng  the  trocar 
nearly  in  a  horizontal  diredion  ;  for,  in  paiTing  it  ob- 
liquely down  towards  the  centre  of  the  pelvis,  the 
bladder,  on  being  left  empty,  v/ould,  in  a  great  pro- 
portion of  cafes,  Idc  apt  to  flip  off  from  the  end  of  it, 
by  which  the  urine  would  be  extravafated,  and  lodge 
in  the  contiguous  parts.  As  foon  as  the  trocar  has 
piercecf  the  bladder,  the  ftilette  fliould  be  withdrawn, 
and  the  canula  fecured  in  its  fituation  with  pieces  of 


234  SuppreJJion  of  Urine.        Chap.  XXXI. 

ribbon  or  tape  conneded  with  it,  tied  to  a  circular 
bandage,  palfed  round  the  body.  , 

The  length  of  the  canula  ul'ed  in  this  operation  is,* 
I  may  remark,  a  point  of  the  lirll  importance,  and 
merits  particular  attention  ;  for  much  inconvenience 
would  arife  from  its  being  too  fliort,  while  a  long  ca- 
nula, as  I  have  already  obferved,  is  apt  to  injure  the 
back  part  of  the  bladder.  Of  this  we  have  an  inllance 
on  record,  in  which  the  end  of  the  canula  was  found, 
after  death,  to  have  penetrated  not  only  the  back  part 
of  the  bladder,  but  even  the  reclum.* 

In  corpulent  people,  the  canula  may  require  to  be 
two,  three,  or  even  more  inches  in  length,  according 
to  the  quantity  of  fat  between  the  Ikin  and  bladder  ; 
but  in  thin  patients,  I  know  from  experience,  that  an 
inch  and  half  is  fufTicient. 

The  canula,  it  mud  be  remembered,  fliould  be  re- 
tained in  its  fituation  till  the  caufe  of  the  obftru«5lion 
is  fo  far  removed,  that  the  urine  can  be  pafl'ed  in  the 
ufual  manner  ;  but  it  has  been  very  properly  remark- 
ed,! that  a  canula  cannot  be  kept  above  ten  or  four- 
teen days  in  the  bladder,  but  with  the  rilk  of  contract- 
ing a  calculous  cruft,  that  renders  its  extraction  both 
r  difficult  and  painful.  The  canula,  therefore,  fhould 
be  taken  out  and  cleaned,  from  time  to  time.  This 
has  commonly  been  done,  by  paffing  a  firm  probe  of 
a  fufficient  thicknefs  through  it  into  the  bladder,  upon 
M'hich  the  canula  is  again  returned,  on  being  cleared 
of  the  incruftadon.  Inftead  of  a  probe,  however,  I 
have  employed  a  tube  that  anfwers  better.  This  tube 
is  made  to  fit  the  diameter  of  the  canula  exa6lly,  but 
at  the  fame  time  to  pafs  eafdy  through  it ;  and  it  has 
this  advantage  over  a  probe,  that  in  the  event  of  its 
proving  difficult  to  return  the  canula  of  the  trocar,  as 
fomecimes  is  the  cafe,  the  tube  may  be  retained  ;  and 
being  nearly  of  the  fame  diameter,  it  anfwers  the  pur- 

*  vide  Shnrpe's  Operations  of  Surgery,  Chap.  XV.      »  j 

f  Vide  Critical  Enijuir y,  &c.  by  Mr.  Sharpe,  Chap.  IV.  { 


Chap.  XXXI.        Supprejfton  of  Urine.         .  235 

pofe  equally  well.  Of  this  tube,  and  the  mode  of 
applymg  it,  I  have  given  a  delineation  and  defcriptioa 
in  Plate  LVI.  and  in  Plate  LVIl.  I  have  delineated  a 
very  neat  apparatus  for  punduring  the  bladder  above 
the  pubes,  by  Dr.  Monro. 

In  punduring  the  bladder  from  the  perinseum,  the 
patient  fliould  be  placed  upon  his  back  on  a  firm  ta- 
bic ;  and  his  thighs  being  feparated,  and  properly  fe- 
cured  by  airiftants,  an  incifion  fliould  be  made  of  an 
inch  and  half  in  length,  beginning  at  the  commence- 
ment of  the  membranous  part  of  the  urethra,  and  pro- 
ceeding towards  the  anus,  in  a  Hne  parallel  to,  but  at 
leafl  half  an  inch  diftant  from,  the  rapha  perin^ei.  In 
this  manner  the  fkin  and  cellular  fubftancc  (hould  be 
freely  divided  ;  which  puts  it  in  the  power  of  the  op- 
erator not  only  to  introduce  the  trocar  with  more  eafe, 
but  to  avoid  the  urethra  with  more  certainty  than  he 
otherwife  could  do. 

This  being  done,  as  the  bladder  is  always  much  dif- 
tcnded  when  this  operation  is  neceffary,  it  is  eafily  dif- 
tinguifhed  with  the  finger  at  the  bottom  of  the  wound  : 
but,  whether  it  is  felt  by  the  finger  or  not,  we  flioulJ 
not  hefitate  to  pulh  in  the  trocar  a  little  above,  and 
to  the  left  of  the  proftate  gland,  which,  when  the  parts 
have  been  freely  divided,  is  eafily  difcovered  ;  and  if 
the  point  of  the  trocar  is  pafTed  up  towards  the  pubes, 
there  can  be  no  danger  of  hurting  either  the  ureters 
or  vafa  dcferentia,  which  fome  have  been  afraid  of  in 
this  operation  ;  and  at  the  fame  time  there  muft  be  an 
abfolute  certainty  in  this  diredion,  if  the  trocar  is  car- 
ried to  a  fufficient  depth,  of  its  reaching  the  bladder. 

It  has  been  alleged,  and  with  fome  reafon,  that  in 
this  part  of  the  operation  the  furgeon  muft  be  at  a  lofs 
to  know  when  the  inftrument  has  reached  the  blad- 
der ;  and  feveral  inventions  have  been  propofed,  to  ob- 
viate this  inconvenience.  In  Plate  LXXIII.  fig.  5.  is 
reprefented  a  very  fimple  contrivance  for  this  purpofe ! 
*  it  confifls  of  a  trocar,  with  a  canula  of  the  ulual  form, 
and  a  deep  groove  in  the  (tilette,  fo  that  urine  begins 


236  Supprcjfion  of  Urine.        Chap.  XXXI. 

to  flow  along  the  groove,  immediately  on  ihe  inflru- 
ment  having  entered  the  bladder.  As  foon,  therefore, 
as  in  this  manner  we  know  that  the  trocar  has  pafled 
to  a  fufficient  depth,  the  fl:ilette  Ihould  be  withdrawn  ; 
when  the  canula  fliould  be  fecured  by  two  pieces  of 
tape,  conneded  with  two  rings  upon  its  brim,  being 
firmly  tied  to  a  circular  bandage  round  the  body  : 
and  if  one  of  thefe  tapes  is  tied  behind  immediately 
above  the  facrum,  and  the  other  directly  above  the 
pubes,  the  canula  will  not  be  eafily  difplaced. 

It  is  equally  neceffary  here  as  when  the  operation  is 
done  above  the  pubes,  to  change  the  canula,  or  at  lead 
to  clean  it  from  time  to  time ;  and  in  this  fituation 
too,  fo  long  as  a  canula  is  employed,  the  urine  may 
be  retained  and  drawn  off  at  pleafure,  by  a  plug  of 
cork  being  fixed  in  it. 

In  perforating  the  bladder  from  the  re6lum,  the  pa- 
tient fhould  be  placed  upon  his  back,  and  fecured  with 
afllflants  in  the  manner  1  have  pointed  out :  the  fur- 
geon  now  inferts  the  forefinger  of  his  left  hand  into 
the  reftum,  and  having  carried  the  point  of  it  about 
an  inch  above  the  proflate  gland,  where  the  bladder 
in  this  diftended  ftate  of  it  is  eafily  felt,  a  curved  tro- 
car about  two  inches  and  a  half  in  length,  ffiould  be 
pafled  along  the  finger,  and  puflied  at  this  prominent 
part  of  the  bladder,  in  an  oblique  direction  upwards 
till  it  reaches  the  urine.  In  this  fituation,  the  canula 
muft  either  be  retained  by  being  fixed  with  pieces  of 
fmall  tape  to  a  circular  bandage  round  the  body,  or  a 
tube  of  refina  elaftica  fliould  be  inferted  through  it, 
and  left  in  the  opening  till  the  urine  paflfes  off  by  the 
urethra. 

This  operation  has  now  been  frequently  praftifed, 
but  it  is  liable  to  fo  many  important  objeftions,  that 
I  do  not  fuppofe  that  it  will  ever  be  generally  adopted. 
It  is  eafily  performed,  but  this  is  almofl  the  only  cir- 
cumflance  that  tends  to  recommend  it.  The  chief 
objections  to  it  are,  the  rifle  incurred  by  it,  of  wound- 
ing either  the  ureters,  vafa  deferentia,  or  veficulse  fe- 


Chap.  XXXI.        Supprejion  of  Urine,  ^2>7 

minales,  while,  at  the  fame  time,  it  forms  a  paffage, 
by  which  the  fseces  may  find  accefs  to  the  cavity  of 
the  bladder,  that  would  either  foon  end  in  the  death 
of  the  patient,  or  leave  him  in  a  date  of  very  mifera- 
ble  exiftence.  Much  irritation  and  diftrefs  mull  alfo 
enfue  from  a  canula  being  left  in  the  reclum  during 
the  cure,  that  is,  till  the  urine  pafles  off  by  the  natur- 
al conduit  of  the  urethra,  which,  in  fome  inftances, 
does  not  happen  in  lefs  than  a  year  or  two,  while  in 
others  the  ftoppage  continues  during  life.  Mr.  Wel- 
don,  who  has  written  an  ingenious  treatife  on  this  fub- 
ject,  indeed  fays,  that  the  canula  may  be  withdrawn 
foon  after  the  operation,  and  the  lirine  allowed  to  pafs 
off  by  the  opening.*  But,  befides  the  very  uncom- 
fortable ftate  to  which  this  would  reduce  the  patient, 
by  having  his  urine  at  all  times  pafling  oif  by  the  rec- 
tum ;  the  opening  would  often  be  apt  to  heal  from 
time  to  time,  by  which  the  operation  might  be  fre- 
quently to  renew. 

I  have  thus  defcribed  the  different  modes  that  have 
been  propofed  of  punduring  the  bladder.  In  appre- 
ciating the  merits  of  each,  I  was  at  one  time  of  opin- 
ion, that  doing  it  from  the  perinseum  was  the  beft  ; 
and  in  the  former  editions  of  this  work,  I  freely  faid 
fo.  I  now,  however,  think  it  right  to  fay,  that  farth« 
er  experience  has  convinced  me  that  I  was  wrong. 
Every  method  of  performing  this  nice  operation,  is  at- 
tended with  difficulties.  I  have  already  enumerated 
thofe  that  chiefly  apply  to  the  mode  of  doing  it  from 
the  re6lum.  To  the  perforation  above  the  pubes,  it  is 
objected,  that  the  cavity  of  the  abdomen  may  be  pierc- 
ed with  the  trocar ;  that  the  bladder  may  be  injured, 
by  being  fufpended  for  a  confiderable  time  upon  the 
canula  ;  that  it  may  even  flip  off  from  the  end  of  the 
canula,  by  which  all  the  urine  will  efcape,  and  lodge 
in  the  pelvis  ;  that  the  end  of  the  canula  may  injure 

•  Vide  Obfervations  on  the  different  modes  of  pundluringthe  bladder, 
by  Walter  Wtldoii,  furgcon. 


>•*&« 


238  SiipprcJJton  of  Urine,        Chap.  XXXL 

the  back  part  of  the  bladder ;  and  that  the.  urine,  in- 
iinuating  into  the  cellular  fubftance  of  the  contiguous 
parts,  may  terminate  in  various  diflrefsful  fymptoms. 

It  may  be  obferved,  however,  in  anfwer  to  thefe  dif- 
ficulties, that  where  the  operation  is  properly  conduc- 
ed, few  or  none  of  them  ever  occur.  It  can  feldom 
or  never  be  neceffary  to  pundlure  the  bladder,  till  it  is 
fo  much  diftended  with  urine,  as  to  be  confiderably 
raifed  above  the  pubes ;  in  which  fituation,  there  is 
no  rifk  of  pufliing  the  trocar  into  the  abdomen.  A 
fuppreflion  of  urine  may  no  doubt  happen,  where  the 
bladder,  by  difeafe,  is  fo  much  contraded,  that  this 
degree-  of  diftentioif  cannot,  confjftently  with  the  fafe- 
ty  of  the  patient,  be  permitted.  I  conclude,  however, 
that  this  is  uncommon,  as  I  have  never  yet  met  with 
it ;  and  v/herever  it  takes  place,  the  difeafed  fhate  of 
the  bladder  will  give  little  or  no  chance  to  the  opera- 
tion, wherever  it  may  be  performed.  I  know  from 
experience,  that  the  bladder  is  not  apt  to  be  hurt  by 
being  fufpended  on  the  canula  ;  and  I  conclude  that 
this  may,  in  fome  meafure,  happen,  from  thofe  attach- 
ments that  commonly  take  place  in  this  difeafe,  be- 
tween the  bladder  and  contiguous  parts,  as  the  effect 
of  the  inflammation,  with  which  a  fuppreffion  of  urine 
is  for  the  mofl  part  attended,  Thofe  adhefions  of  the 
bladder  to  the  contiguous  parts,  may  alfo  in  fome 
meafure  tend  to  prevent  the  bladder  from  flipping  off 
from  the  canula  ;  but  this  accident  can  never  poffibly 
happen,  if  the  trocar  is  not  introduced  with  too  much 
obliquity  downwards.  Neither  vnll  the  back  part  of 
the  bladder  be  hurt  by  the  canula,  if  the  direftions  I 
have  given,  in  regard  to  the  length  of  it,  are  kept  in 
view^,  and  if  the  blunt  filver  flopper,  Plate  LVI.  fig.  3. 
is  always  kept  in  it,  except  when  the  patient  is  voiding 
urine. 

That  difl:refsful  fymptoms  may  enfue,  from  the  urine 
finding  accefs  to  the  contiguous  cellular  fubfl:ance, 
none  will  doubt,  but  I  have  now  much  reafon  to  think 
that  it  is  an  uncommon  occurrence  in  this  operation. 


Chap.  XXXI.        Supprefflon  of  Urine.  239 

In  perforating  from  the  perinceum,  to  which  at  one 
time  I  gave  the  preference,  the  urine  is  ftill  more  apt 
to  efcape  from  the  wound,  into  the  contiguous  cellu- 
lar fubltance  ;  although  this  is  by  no  means  the  moil 
important  objedion  to  the  operation  being  done  in  that 
fituation.  The  chief  danger  here,  arifes  from  the  near 
contiguity  of  very  important  parts,  the  urethra,  prof- 
tate  gland,  ureters,  vaffe  deferential,  and  veficulas  fe- 
minales,  which  being  all  near  the  neck  of  the  bladder, 
and  therefore  apt  to  inflame,  whenever  the  urine  is 
long  fupprelfed,  they  muft  necefTarily  be  more  fevere- 
ly  injured,  by  the  trocar  paffing  near  them,  and  by 
their  being  freely  expofed  to  the  air,  by  the  deep  in- 
cifion  in  the  previous  fteps  of  the  operation,  than  the 
upper  part  of  the  bladder  can  poffibly  be,  in  perforat- 
ing above  the  pubes,  and  accordingly  more  danger  is 
found  to  attend  it. 

I  an\  therefore  of  opinion,  on  a  comparative  view 
of  the  advantages  and  difadvantages  of  thefe  feveral 
operations,  that  punfturing  the  bladder  above  the 
pubes  is  the  bed.  I  have  only  further  to  obferve,  be- 
fore leaving  the  fubject,  that  in  whatever  way  the  op- 
eration is  done,  it  ihould  not  be  long  poflponed  after 
the  bladder  becomes  painfully  diflended  :  I  have  often 
indeed  been  led  to  think  that  more  danger  has  enfued 
from  delay  in  this  fituation,  by  which  the  bladder  has 
appeared  to  be  entirely  deprived  of  its  tone,  than  we 
almofl  ever  meet  with  from  the  mod  untoward  occur- 
rence in  any  of  thefe  modes  of  operating. 

In  the  operation  of  lithotomy  in  females,  I  men- 
tioned reafons  that  appear  to  be  conclufive  againll 
the  method  of  cutting  into  the  bladder  from  the  vagi- 
na ;  but  they  do  not  apply  with  equal  force  againft 
the  propriety  of  puncturing  the  bladder  in  this  part. 
On  the  contrary,  whenever  there  is  caufe  for  perform- 
ing this  operation  in  women,  it  cannot  be  done  in  any 
other  way,  either  with  fuch  eafe  or  certainty,  as  from 
the  vagina.  When  the  bladder  is  much  diflended 
with  urine,  it  is  eafily  difcovered  by  the  finger  in  the 


240  Svppvejfton  of  Urine,        Chap.  XXXl, 

vagina  ;  and  from  thence  it  may  with  fafety  be  pier- 
ced with  a  trocar.  The  forefinger  of  the  left  hand 
being  pafled  into  the  vagina,  the  point  of  the  trocar 
fliould  be  conduced  upon  it,  and  pufhed  through  the 
vagina  into  that  part  of  the  bladder  firlt  difcovered  by 
the  finger  ;  for  here  the  ureters  run  no  rifk  of  being 
wounded,  which  farther  back  they  certainly  would  do. 
The  trocar  being  freely  paiTed  into  the  bladder,  and 
the  urine  all  evacuated,  the  canula  fliould  be  left  in 
its  place,  and  continued  as  long  as  the  caufe  fubfifts 
by  which  the  fupprefiion  was  produced.  That  the 
tube  may  be  firmly  fecured,  it  fnould  be  of  a  fuffi- 
cient  length  for  palling  out  at  the  vagina,  and  to  ad- 
mit of  its  being  tied  to  the  T  bandage,  with  tapes  at- 
tached to  it. 

I  think  it  here,  however,  proper  to  obferve,  that  in 
whatever  way  the  bladder  is  punclured,  and  v>hether 
in  male  or  female  patients,  if  tubes  of  filver  irritate 
and  excite  pain,  as  is  very  apt  to  be  the  cafe,  that  this 
may  in  moA:  inilances  be  prevented  by  leaving  in  the 
palfage  a  tube  of  elaitic  refin. 


Chap.  XXXII.         Obftruaiom,  ^a  441 


CHAPTER    XXXII. 


OBSTRUCTIONS    IN    THE    URETHRA. 


IN  the  preceding  fe6lion,  when  treating  of  the  cauf- 
es  of  fuppreflion  of  urine,  obftruclions  produced 
by  chips,  of  which  caruncles  are  fuppofed  to  be  the 
moll  frequent,  were  fpoken  of  as  the  niofl:  frequent 
and  mod  remarkable. 

But  although  I  have  particularly  mentioned  the 
term  caruncle,  by  which  is  meant  a  tlefliy  excrefcence 
arifmg  from  the  membrane  of  the  urethra,  J  do  not 
tvifli  it  to  be  fuppofed  that  I  confider  it  to  be  a  fre- 
quent occurrence.  That  fuch  excrefcences  are  fome- 
times  met  with  towards  the  extreuiity  of  the  yard, 
there  is  no  reafon  to  doubt ;  but  as  I  have  often  dif- 
fecled  thefe  parts,  in  patients  who  had  long  laboured 
under  fymptoms  fuppofed  to  proceed  fn*m  caruncles 
in  the  back  part  of  the  urethra,  and  as  caru'icles  were 
not  difcovcred  in  any  of  tliem,  I  am  therefore  of  opi- 
nion that  their  exiftence  in  the  more  remote  parts  of 
the  urethra  is  very  uncommon.  I  have  often  obferv- 
ed  this  kind  of  produfftion,  within  a  quarter  of  an  inch 
of  the  extremity  of  the  urethra,  efpccially  where  the 
glans  and  prepuce  have  been  covered  wi:h  warty  ex- 
crefcences of  a  funilar  nature  ;  but  from  having  never 
found  them  fpread  farther  up  the  canal,  although  it 
is  not  a  proof  that  they  never  occur  in  other  parts  of 
it,  yet  this,  together  with  fome  obiervations  of  a  fimi- 
lar  nature  by  Dionis,  Saviard,  Mr.  Prtit,  and  others, 
IS  fufficient  authority  for  the  opinion  I  have  advanced, 
that  caruncles  in  the  more  remote  parts  of  the  urethra 
are  rarely  met  with.  Daran  indeed  often  fpeaks  of 
them ;  and  he  no  doubt  had  more  pradice  in  difeafos 
Vol.  in.  R 


242  Ohjlrudious  in  Chap.  XXXII. 

of  this  clafs  than  perhaps  ever  fell  to  the  fliare  of  any 
other  individual :  but  if  his  works  are  read  with  atten- 
tion, it  will  appear  that  his  detail  is  very  inaccurate  ^ 
for  he  evidently  confounds  other  caufes  of  obftruftion^ 
particularly  flriclures  and  cicatrices  of  old  ulcers, 
with,  and  niiflakes  thein  for,  caruncles. 

Pra(5litioners  in  former  times,  as  well  as  many  in 
more  late  periods,  have  doubted  fo  little  of  the  fre- 
quent occurrence  of  caruncles,  that  almofl  every  in- 
ftance  of  obflrufted  urethra  fucceeding  to  a  clap  has 
been  attributed  to  this  caufe.  What  I  have  here  fet 
forth  will  tend  to  fet  this  however  in  a  difierent  view  ; 
and  I  fhall  now  proceed  to  enumerate  the  different 
caufes  by  which  obftrudlions  in  the  urethra  may  be 
produced. 

1 .  Although  I  have  fald  that  caruncles  are  rarely 
met  with  in  the  fuperior  part  of  the  urethra,  yet  they 
fometimes  form  towards  the  extremity  of  this  canal : 
they  muft  therefore  be  mentioned  as  one  caufe  of 
thefe  obftruclions.  I  muft  again  obferve,  however, 
that  where  caruncles,  or  carnofities  as  they  are  fome- 
times termed,  are  met  with,  they  are  always  of  the 
fame  nature  with  thofe  warty  excrefcences  that  fre- 
quently form  upon  the  prepuce  and  glans  as  a  confe- 
quence  of  gonorrhoea. 

2.  Ulcers  in  different  parts  of  the  urethra  have  been 
known  to  produce  very  complete  obftrudions. 

On  opening  the  bodies  of  thofe  who  at  the  time  of 
death  laboured  under  gonorrhoea,  ulceration  has  very 
feldom  been  difcovered  ;  and  this  gave  rife  to  the  opi- 
nion that  ulcers  of  the  urethra  never  take  place  in 
gonorrhoea.  We  now  know  indeed  that  very  great 
quantities  of  matter  may  be  furnifhed  by  parts  mere- 
ly inflamed,  and  not  in  a  ftate  of  ulceration.  But  we 
alfo  know,  that  parts  remaining  for  any  confiderable 
length  of  time  fo  highly  inflamed  as  to  furnifh  much 
pus,  are  very  ^pt  to  become  ulcerated ;  and  if  this 
happens  in  other  parts  of  the  body,  we  may  conclude 
that  the  fame  caufe  will  induce  the  fame  eifeds  in  the 


Chap.  XXXII.  the  Urethra.  243 

urethra.  Accordingly,  there  is  no  reafon  to  doubt  of 
ulcers  arifing  in  the  urethra  from  inflammation  alone  ; 
but  it  is  iikewife  certain,  that  they  are  fometimes,  met 
with  in  the  urethra  from  the  fame  caufe  by  which 
chancres  are  produced  in  the  glans,  namely,  from  the 
mechanical  effecls  of  the  veneral  poifon,  independent 
of  the  intervention  of  any  degree  of  inflammation. 

The  excretory  duels  of  the  diff'erent  glands  in  the 
urethra,  particularly  of  the  proflate  gland,  as  alfo  the 
duels  of  the  veficul^  feminales,  and  the  other  parts 
about  the  verumontanum,  have  commonly  been  fup- 
pofed  to  be  particularly  obnoxious  to  the  effecls  of  the 
venereal  virus ;  and  ulcerations  are  accordingly  faid 
to  be  more  frequent  in  thefe  parts  than  in  others.  The 
refult  of  my  obfervation,  however,  has  been,  that  ul- 
cers feldom  occur  in  any  part  of  the  urethra,  but 
more  frequently  towards  the  extremity  of  the  urethra 
than  in  other  parts  of  it,  and  that  they  rarely  form 
farther  back  than  an  inch  or  fo  from  the  point  of  the 
yard. 

3.  Diflfedlion  has  fhewn,  that  a  mere  contraded 
(late  of  the  urethra  is  to  be  confidered  as  the  moft 
frequent  caufe  of  obftrudion.  In  fome,  the  ftriclure 
is  confined  to  one  point,  while  in  others  different  parts 
of  the  paffage  are  difeafed.  At  one  period,  I  was  in- 
duced to  think  that  ftridures  in  the  urethra  were  more 
frequently  produced  by  ulceration  than  in  any  other 
way  ;  but  I  have  now  reafon  to  think,  that  they  pro- 
ceed more  frequently  from  that  thickened  ftate  of  the 
membrane  of  the  urethra  that  gonorrhoea  is  apt  to 
excite. 

Aflringent  injeclions  are  mentioned  by  many  as  a 
frequent  caufe  of  flridlures.  Irritating  injeclions,  when 
improperly  applied  to  parts  already  in  a  flate  of  in- 
flammation, may  no  doubt  do  harm  ;  and,  by  increaf- 
ing  the  inflammatory  ftate  of  the  urethra,  may  in  this 
manner  produce  ftriclures  :  but  this  is  not  the  fault 
of  the  remedy,  but  of  the  improper  ufe  of  it.  Similar 
R  2 


244  VbftrtiBions  in  Chap.  XXXIL 

obje£lions  might  with  equal  reafon  be  adduced  againft 
the  ufe  of  every  medicine  with  which  we  are  acquaint#. 
ed  ;  for  few  remedies  are  more  fafe  in  their  operation, 
or  more  effedual  in  the  cure,  than  aftringent  injec- 
tions in  gonorrhoea.  Obftinate  claps  indeed  are  often 
cured  by  injedions  that  cannot  be  removed  in  any 
other  way. 

4.  Tumors  in  the  cellular  fubflance  furrounding 
the  urethra,  or  in  any  of  the  glands  connected  with  it, 
very  frequently  produce  obllruclions  in  the  courfe  of 
it :  and  inflammation,  whether  at  firft  produced  by 
gonorrhoea,  or  in  any  other  way,  when  it  terminates 
in  fuppuration,  mud  be  apt  to  induce  them.  In  fuch 
cafes,  indeed,  as  foon  as  the  matter  collected  in  the 
abfcefs  is  difcharged,  the  obflruQion  produced  by  it 
is  in  general  removed :  in  fome  inftances,  however, 
this  does  not  happen ;  for  in  different  cafes  I  have 
found,  that  the  compreflion  produced  by  the  tumor 
has  induced  fuch  firm  adhefion  between  the  fides  of 
the  urethra,  as  to  obliterate  the  canal  entirely.  In 
which  cafe,  as  a  total  Hop  is  put  to  the  natural  dif- 
charge  of  urine,  it  burfts  out  in  the  perinasum,  where 
one  or  more  openings,  communicating  with  the  ure- 
thra, are  found  between  the  feat  of  the  difeafe  and  the- 
proftate  gland. 

5.  Of  all  the  caufes  of  obftruclion,  none  are  fo  fre- 
quent as  a  fulnefs  or  enlargement  of  the  corpus  fpon- 
giofuin  urethrse.  On  dilfeding  the  penis  of  fuch  as 
have  laboured  long  under  obftrudions,  a  partial  en- 
largement or  thickening  of  the  fubftance  of  the  ure- 
thra, often  appears  to  be  the  caufe,  and  it  frequently 
proceeds  fo  far  as  to  obllru£l  the  paffage  entirely. 

In  fome,  the  ftoppage  is  confined  to  a  particular 
point :  in  others,  it  is  of  confiderable  extent ;  while 
not  unfrequeritly  it  attacks  different  parts  of  the  canal> 
leaving  intermediate  parts  perfedlly  found. 

6.  Having  thus  enumerated  the  caufes  that  mofl 
frequently  produce  obftrm^ions  in  the  urtthra,  I  fhall 


Chap.  XXXII.  tie  Urethra,  245 

now  endeavour  to  point  out  the  treatment  befl  calcu- 
lated for  their  removal. 

When  the  obflruftion  is  produced  by  the  preflure 
of  a  tumor,  our  practice  muft  depend  on  the  kind 
Jind  nature  of  the  tumor.  Accordingly,  when  the  tu- 
mors are  hard  and  indolent,  they  ought  to  be  extir- 
pated whenever  it  can  be  done  with  fafety.  But  al- 
though this  may  be  done  when  they  do  not  penetrate 
deep,  yet  when  the  proftate  gland,  or  any  of  the  parts 
about  the  neck  of  the  bladder,  are  found  to  be  enlarg- 
ed, the  removal  of  thefe  cannot  pofTibly  be  attempted. 
In  fuch  defperate  cafes,  cicuta  has  been  often  ufed ; 
but  feldom,  I  believe,  with  advantage.  In  an  ulcerat- 
ed ftate  of  the  parts,  a  plentiful  ufe  of  uva  urfi  has 
been  known  to  give  relief,  and  fome  advantage  has 
occafionally  been  derived  from  a  gentle  courfe  of  mer- 
cury. The  effeft,  however,  of  mercury,  in  all  affec- 
tions of  this  kind  is  by  no  means  certain  ;  and  in  the 
diftrefs  that  this  variety  of  the  difeafe  excites,  we  are 
frequently  reduced  to  the  neceflity  of  trufting  entire- 
ly to  the  relief  which  opiates  give,  and  to  a  plentiful 
ufe  of  mucilaginous  drinks. 

When,  again,  the  tumors  proceed  from  inflamma- 
tion, if  they  are  not  foon  difcuffed,  the  mofl  elfeftual 
means  (hould  be  employed  for  bringing  them  to  fup- 
puration. 

Thefe  having  been  enumerated  in  Chapter  I.  it  is 
not  necefl'ary  to  repeat  them,  and  as  foon  as  the  for- 
mation of  matter  is  accomplifhed,  it  ought  to  be  dif- 
charged.  In  other  parts  of  the  body,  when  an  in- 
flammatory tumor  is  likely  to  terminate  in  fuppura- 
tion,  we  confider  it  as  good  practice  not  to  open  the 
abfcefs  till  pus  is  thoroughly  formed  ;  but  in  this  fitu- 
ation,  as  much  diflrefs  would  enfue  from  delay,  the 
abfcefs  fliould  be  opened  as  foon  as  there  is  caufe  to 
imagine  that  the  prefTure  upon  the  urethra  would  be 
diminifhed  by  doing  fo  ;  and  this  mufl  always  be  the 
cafe  when  a  fluduation  of  matter  is  evidently  difcov- 
ered.     In  all  fuch  cafes,  we  remove  the  obflrudioft 


24^  Ohjlrud-iom  in  Chap.  XXXII. 

In  the  urethra  with  more  certainty  by  difcharging  the 
matter  contained  in  the  abfcefs  than  by  any  other 
means.  If,  on  laying  the  colleclion  open,  however, 
if  is  found  that  the  itoppage  in  the  urethra  is  not  re- 
moved, bougies  fliould  be  immediately  employed.  By 
pafTmg  a  bougie  of  a  proper  fize  along  the  urethra, 
and  allowing  it  to  remain  for  two  or  three  hours  dai- 
ly, any  flricture  produced  by  the  preflure  of  the  ab- 
fcefs will  foon  be  removed. 

It  fometimes  happens,  where  abfceffes  in  this  fitua- 
tlon  have  been  of  long  duration,  that  the  urine  burfts 
into  the  cellular  membrane  of  the  perina?um  and  oth- 
er contiguous  parts,  and  from  thence  forms  one  or 
more  external  openings.  One  of  the  mofl  diflrefsful 
fituations  is  in  this  manner  induced,  to  which  the  hu- 
man body  is  liable,  a  difeafe  of  which  we  fhall  more 
particularly  confider  in  fpeaking  of  fiflula  in  perinaeo. 
In  the  other  cafes  of  obflruded  urine,  proceeding  from 
caruncles  when  they  happen  to  occur ;  from  ulcers, 
and  the  cicatrices  which  they  produce  ;  from  ftrifture 
and  contraction  of  the  urethaa ;  or  from  an  enlarged 
and  thickened  ftate  of  the  corpus  fpongiofum  urethrse, 
we  depend  almoft  entirely  on  a  proper  application  of 
bougies,  a,  remedy  that  proves  chiefly  ufeful  by  its 
mechanical  adion  on  the  obftrucled  part.  It  has  been 
alleged,  indeed,  by  many,  particularly  by  Mr.  Daran. 
and  Mr.  Sharpe,  that,  in  removing  caruncles  and  oth- 
er caufes  of  obftruftion,  bougies  prove  more  ufeful 
by  what  they  term  their  fuppurative  quality,  than  by 
any  other  property :  by  which  they  mean  to  fay,  that 
bougies  may  be  compofed  of  fuch  materials  as  will  in- 
duce a  fuppuration  upon  the  caruncles  to  which  they 
are  applied  ;  and  that  this  fuppuration,  if  continued 
for  a  fufficient  length  of  time,  will  ultimately  deftroy 
all  the  difeafed  parts.* 

*  For  Mr.  Daran's  account  of  this  matter,  fee  his  Treatife  on  Difeafes, 
of  the  Urethra :  and  Mr.  Sharpe's  account  of  It  may  be  feen  in  his  Cri- 
tical Enquiry,  chap.  vi.  Although  Mr.  Sharpe  is  clearly  of  opinion,  that 
tjjie  principal  advantage  derived  from  bougies  proceeds  from  their  influ-^ 


Chap.  XXXII.  the  Urethra.  ii^y 

This  idea,  although  founded  on  inaccuracy,  contin- 
ues with  many  ftiil  to  prevail :  little  argument,  how- 
ever is  required  to  fhew  that  bougies  a6t  chiefly  by 
their  mechanical  prlTure,  and  not  by  the  fuppuration 
which  they  excite.  Among  other  reafons  that  might 
be  given  as  proofs  of  this,  I  fhall  only  mention  the 
following. 

1 .  Thofe  who  allege  that  bougies  prove  ufeful  only 
by  inducing  fuppuration,  are  obliged  to  afl'irm  that  ob- 
flruclions  to  the  pafTage  of  urine  arife  mofl:  frequent- 
ly from  caruncles  in  the  urethra  ;  and  that  the  fuppu- 
ration produced  by  the  bougies,  tends  to  deflroy,  or 
as  it  were  to  diifolve,  them  ;  but  although  thefe  ex- 
crefcences  may  fometimes  prove  the  caufe  of  obftruc- 
tions,  yet,  as  I  have  already  endeavoured  to  fhew, 
they  are  very  rarely  met  with.  It  mufl  therefore  fol- 
low, if  this  idea  of  the  caufe  of  the  difeafe  is  ill  found- 
ed, that  the  fuppofed  modus  operandi  of  the  remedies 
employed  in  it  muft  likewife  be  erroneous  ;  for  every 
practitioner  who  gives  attention  to  this  branch  of  his 
profeflion,  mud  acknowledge,  that  bougies  prove 
much  more  frequently  ufeful  than  the  caufe  upon 
which  they  have  been  fuppofed  chiefly  to  operate  is 
found  to  exifl.  Indeed,  the  general  utility  of  bougies 
in  obflrudions  of  the  urethra,  mufl  be  acknowledged 
by  all  who  have  ufed  them,  while  fcarcely  any  advan- 
tage is  derived  from  any  other  remedy. 

2.  But  although  we  fhould  allow  that  caruncles  are 
frequently  formed  in  the  urethra,  we  cannot  admit 
that  fuppuration  induced  upon  them  would  have  much 
influence  in  removing  them, 


cnce  in  inducing  fuppuration,  yet,  whenever  he  argues  on  this  with  accu» 
racy,  he  is  obliged  to  acknowledge,  that  by  their  preflure  alone  they  prove 
ufeful :  for  he  fays,  "  Tliat  though  I  have  a  great  opinion  of  the  good  ef- 
fcdls  produced  by  the  fuppuration,  yet  I  believe  alfo,  that  bougies  oper- 
ate by  diftending  the  urethra  ;  and  I  will  go  fo  far  as  to  give  it  as  my 
judgment,  that  even  the  cures  done  by  Mr.  Daran  are  wrought  partly  by 
diftcntion,  and  partly  by  fuppuiation';  though  he  himfclf  afcribes  theni 
to  fuppuration  only."     Vide  page  171,  fourth  edition,  loc.  cit. 


248  Ohjiruaiom  in  Chap.  XXX 11. 

We  know,  that  in  other  parts  of  the  body,  warts 
and  other  hard  excrelcences  cannot  be  carried  off 
merely  by  matter  being  formed  upon  them  ;  and  we 
cannot  fuppofe  that  in  this  there  is  much  dift'erence 
between  warts  in  the  urethra,  and  thofe  wliich  form 
in  other  parts  of  the  body. 

3.  It  has  been  faid,  that  thefe  bougies,  while  they 
a«3:  by  inducing  fuppuration,  have  likewife  fome  influ- 
ence as  efcharotics ;  and  that  manv  of  Mr.  Daran*s 
bougies,  the  compofition  of  which  was  kept  fecret, 
were  evidently  poflefled  of  this  property.  Mr.  Daran, 
in  order  to  render  the  operation  of  his  remedy  as  myf- 
terious  as  poflible,  did  indeed  allege,  that  his  bougies 
"Were  endowed  with  many  virtues  :  but  no  candid  prac- 
titioner will  fay,  that  bougies  pofleffed  of  a  degree  of 
cauflicity  fufficient  to  deflroy  warts,  can  with  propri- 
ety be  palled  into  the  urethra  ;  for,  if  of  fuch  a  ftrength 
as  to  corrode  thefe  excrefcences,  they  would  neceflari- 
ly  injure  the  whole  of  the  urethra  to  which  they  are 
applied.  Indeed,  the  mildeft  materials  we  can  employ 
frequently  ftimulate  too  much  :  for,  upon  withdraw^ 
ing  any  bougie  that  has  remained  long  in  the  urethra, 
it  is  almoft  always  found  covered  with  purulent  mat- 
ter. It  is  this  indeed  I  imagine,  that  firfl:  fuggefted 
the  idea  of  bougies  acling  by  inducing  fuppuration  ; 
which,  however,  is  to  be  confidered  only  as  a  neceffa-n 
ry  effetl  of  a  ftimulus  applied  to  a  fenfible  membrane, 
being  in  no  refpe£t  eifential  to  the  cure  of  the  difeafe 
for  which  the  bougie  is  ufed. 

•  4.  But  without  having  recourfe  to  the  fuppurative 
or  efcharotic  effects  of  bougies,  the  advantages  com- 
monly derived  from  them  may,  as  I  have  already  en- 
deavoured to  Ihew,  be  eafily  explained  upon  the  prin- 
ciple of  mechanical  prelfure  alone. 

I  have  thus  thought  it  proper  to  confider  the  adion 
of  bougies  with  minutenefs  ;  for  till  the  opinion  is  ex^ 
ploded  of  medicated  bougies,  as  they  are  termed,  be- 
ing neceflfary,  much  mifchief  may  be  done,  by  forming 
them  of  irritating  or  even  of  efcharotic  materials,  as  is 


Chap.  XXXII.  the  Urethra.  249 

fometlmes  the  cafe,  inftead  of  rendering  their  compo- 
fition  mild  and  inoffenfive,  as  in  every  inflance  it  ought 
to  be. 

The  opinion  that  I  have  endeavoured  to  eftablifh 
being  admitted,  namely,  that  bougies  (hould  operate 
folely  by  mechanical  prelTure,  it  muft  necelTarily  fol- 
low, that,  in  the  formation  of  bougies,  much  will  de- 
pend on  their  being  of  a  proper  confiftence  ;  neither 
too  hard  nor  too  foft.  When  too  foft  and  comprefli- 
ble,  they  cannot  aft  with  advantage  againft  the  ob- 
ftrutting  caufe,  and  againft  which  preflure  is  intended 
to  be  applied ;  and  when  too  hard,  they  are  apt  to 
crack,  and  are  neither  introduced  into,  nor  retained  in 
the  urethra,  with  fo  much  eafe  as  when  formed  of  a 
proper  confiftence  :  bougies  ought  likewife  to  have  a 
fmooth  poliftied  furface,  to  facilitate  their  introduc- 
tion ;  and  laftly,  they  ought,  as  I  have  already  remark- 
ed, to  be  compofed  of  very  mild  materials,  fo  that  they 
may  excite  as  little  irritation  a$  poflible. 

Various  formulae  have  been  given  for  bougie  plaf* 
ters  ;  and  of  thefe  the  following  are  perhaps  the  beft,, 
No.  I.  5o«  Emplaft.  Diachyl.  fnnp.  ^iv. 
Cer.  puriflT.  3ifs. 
01.  Oliv.  opt.  3iii. 
No.  2.  5>-  Tniplaft.  commun. 

Sperm  at.  Cet.  aa  ^iv, 

01.  Oliv.  opt.  ^fs. 
Mlnii,  5fs.  M. 
No.  3.  5"  Eniplaft.  commun.  Jvi. 

Cerx  flavas  purift". 

Spermat.  Cet.  aa  ^ii, 

01.  Oliv.  opt.  l\. 

Antimon.  crud.  pp"-  ^fs.  M.  S.  A. 
Any  of  thefe  prefcriptions  afford  a  good  compofi- 
tion  for  bougies.  They  require  to  be  ilowly  melted, 
and  the  different  articles  to  be  well  mixed  together. 
No.  I.  is  the  fimpleft,  and  perhaps  the  beft  ;  the  red 
lead  in  No.  2.  and  antimony  in  No.  3.  being  added 
chiefly  for  the  purpofe  of  affording  a  variety  of  col- 


250  OhJlruBiom  in  Chap.  XXXII. 

our.     No.  4.  is  a  compofition  for  bougies  recommend- 
ed by  Mr.  John  Hunter  ;*  and  No.  5.  by  Mr.  Sharpe.f 
No.  4.  Take  oil  of  oHves,  three  pints  j 
Bees  wax,  one  pound  ; 
Red  lead,  one  pound  and  a  half. 
Let  them  be  boiled  together  on  a  flow  fire  for  fix 
hours. 

No.  5.  Igo.  Diachyl.  cum  pice  Burgund.  Jii. 
Argent,  viv.  ^i. 
Antimon.  crud.  pp"-  5fs. 
The  quickfilver  to  be  previoufly  diflblved  in  balfam 
of  fulphur,  or  in  honey,  and  added  to  the  plafter 
when  melted  in  a  moderate  heat. 

Any  of  thefe  compofitions,  when  boiled  to  a  pro- 
per confidence,  will  anfwer  for  the  formation  of  bou- 
gies, which  is  done  in  the  foUov/ing  manner  :  while 
the  liquid  fliil  continues  warm,  let  a  piece  of  fine  old 
linen  be  dipped  in  it,  taking  care  with  a  fpatula  to 
cover  the  whole.  If  the  melted  Hquor  be  of  a  proper 
heat,  no  more  of  the  plafter  will  adhere  to  the  linen 
than  is  neceflary  ;  but  as  air  bubbles  are  apt  to  arife 
and  produce  inequalities  on  the  furface  of  the  cloth, 
the  fpatula  made  ufe  of  fhould  be  fomewhat  warmer 
than  the  plafter,  and  by  means  of  it  the  whole  fliould 
be  made  fmooth.  The  plafter  might  indeed  be  fpread 
entirely  with  the  fpatula  ;  but  this  is  not  only  attend- 
ed with  more  trouble,  but  it  does  not  cover  the  cloth 
with  fufficient  equality. 

The  cloth  being  fufficiently  cold,  may  be  immedi- 
ately formed  into  bougies,  and  the  whole  fliould,  in 
the  firft  place,  be  cut  into  the  number  that  is  meant 
to  be  made.  The  moft  exact  method  of  doing  this  is 
bv  means  of  a  fliarp  pointed  knife,  direfted  by  a  rule. 
The  pieces  Ihould  be  eleven  inches  in  length  for  bou- 
gies of  a  full  fize  ;  but  they  fliould  likewife  be  kept  of 
all  the  variety  of  lengths  for  llridures  of  diiierent 
heights  in  the  urethra. 

*  See  Treatife  on  the  Venereal  DIfcafe,  p.  137. 
•j-  Sec  Critical  Encjuiry  by  baniuci  Sharpe,  F.  R.  S. 


Chap.  XXXII.  ihe  Urethra.  251 

A  variety  of  diredions  have  been  given  for  the  form 
of  bougies.  Some  advife  them  to  be  made  nearly  of* 
an  equal  thicknefs  to  within  an  inch  of  their  fmallefl 
end,  and  to  taper  from  that  to  the  point,  while  a  great 
proportion  of  them  are  made  to  taper  to  within  an  inch 
or  two  of  the  point,  and  the  reft  of  them  are  cylindri- 
cal. I  once  thought  that  this  laft  form  of  bougie  was 
the  beft  ;  but  after  a  long  courfe  of  experience  in  this 
branch  of  bufmefs,  I  am  now  convinced,  that  bougies, 
which  taper  equally  from  one  end  to  the  other,  arc 
the  beft,  and  that  this  form  anfvvers  equally  well  for 
every  variety  of  fize.  They  are  introduced  more  ea- 
fily,  and  with  lefs  pain  than  any  of  the  others ;  the 
linen  fliould  therefore  be  cut  in  fuch  a  manner  as  to 
give  this  form  to  the  bougies.  When  rightly  fprcad, 
and  the  linen  fufficiently  fine,  a  well  fhaped  bougie 
will  be  formed  of  a  flip  of  about  five-eighths  of  an 
inch  broad  at  its  largeft  end,  and  fomewhat  more  than 
three-eighths  at  the  fmalleft  end.  This  forms  a  bou- 
gie of  a  middle  fizc  ;  for  particular  purpofes  they  muft 
be  confiderably  larger,  and  for  others  not  fo  large  by 
a  great  deal. 

The  flips  of  linen  are  now  to  be  rolled  up  as  neatly 
as  pofTible  with  the  fingers  ;  and  in  order  to  give  them 
a  fmooth  polilhed  furface,  they  fhould  be  fmartly  roll- 
ed between  a  piece  of  fmooth  hard  timber  and  a  plate 
of  fine  poHfhed  marble  :  this  being  continued  till  the 
whole  are  rendered  perfedlly  fmooth  and  firm,  and 
their  points  being  properly  rounded,  in  order  to  facil- 
itate introdudion,  they  are  in  this  ftate  to  be  kept  for 
ufe. 

Thefe  direftions  will  convey  an  idea  of  the  method 
of  preparing  bougies,  but  no  furgeon  can  ever  become 
fo  expert  in  forming  them  as  artifts  daily  accuftomed 
to  prepare  them  in  large  quantities.  I  muft  here, 
however,  remark,  that  bougies,  properly  prepared  with 
refina  elaftica,  are  preferable  in  many  circumfianccs 
to  fuch  as  are  made  with  any  kind  of  plafter.  They 
not  only  prove  much  more'  durable,  but  more  force 


i52  Ohjlrucliom  in  Chap.  XXXIL 

can  be  employed  with  them,  and  as  they  do  not  break 
or  crack  by  continuing  in  the  urethra,  they  remain  in 
it  with  lefs  pain  and  inconvenience  than  any  other  bou- 
gie that  has  yet  been  invented. 

Catgut  has  frequently  been  ufed  as  a  bougie  ;  but 
after  various  trials  being  given  to  it,  I  do  not  find  that 
it  anfwers  the  purpofe :  it  cannot  be  made  fufficiently 
fmooth  ;  and  it  fometimes  fwells  fo  much  as  to  excite 
a  good  deal  of  irritation ;  and  lead,  which  was  one  of 
the  firfl  articles  ufed  for  bougies,  is  fo  firm  that  it  al- 
ways creates  much  pain,  while  it  is  fo  apt  to  break, 
that  difierent  inftances  having  occurred  of  this,  it  has 
now  been  long  laid  afide. 

We  come  now  to  the  application  of  the  bougie.  A 
bougie  muft  be  chofen  adapted  to  the  fize  of  the  paf- 
fage  through  which  it  is  to  pafs,  and  well  covered  with  . 
fine  oil :  the  penis  being  firmly  grafped  and  extended  I 
with  one  hand,  the  end  of  the  bougie  muflbe  inferted 
into  the  urethra  with  the  other  ;  and  being  pufhed 
forward  with  caution,  it  is  in  this  manner  to  be  car- 
ried on  till  it  meets  with  the  caufe  of  obflruftion  ; 
when,  if  a  moderate  force  makes  it  pafs,  our  objecl  is 
fo  far  accomplifhed  :  but  if,  after  different  attempts, 
it  cannot  be  eafily  carried  forward,  it  fhould  be  imme- 
diately withdrawn  ;  and  at  next  trial,  which,  in  order 
to  avoid  any  riflv  of  inflammation,  fhould  not  be  made 
for  two  or  three  days,  a  bougie  with  a  fmaller  point 
ihould  be  employed. 

Much  nicety  is  required  in  this  part  of  the  opera- 
tion ;  for,  by  proceeding  flowly,  with  due  care  and 
caution,  eveiy  riflv  may  be  avoided  of  injuring  the  ure- 
thra, at  the  fame  time  that  the  object  in  view  may  be 
cften  accompliflied  with  more  certainty  than  when 
much  force  is  employed.  As  foon  as  we  reach  the 
caufe  of  obfliruclion,  if  a  bougie  of  the  fmalleft  fize  is 
employed,  infl:ead  of  pufliing  it  on  with  force,  as  to  a 
certain  degree  may  be  done  with  a  catheter,  it  anfwers 
the  purpole  with  more  certainty  to  twirl  it  between 
the  finger  and  thumb,  fo  as  to  make  it  prefs  moder- 


Chap.  XXXII.  the  Urethra,  ^55 

ately  upon  the  part  that  It  ought  to  pafs.  But,  on 
the  other  hand,  ahhough  mifchief  has  often  accrued 
from  too  much  force  being  ufed  with  bougies,  and  al- 
though every  praclitioner  (hould  therefore  be  warned 
of  the  danger  ;  yet,  when  much  refiftance  is  met  with, 
they  muft  neceffarily  be  preffed  on  with  firmnefs,  ijF 
this,  however,  is  done  with  caution,  and  in  a  proper 
diredion,  which  experience  alone  can  teach,  it  may 
very  commonly  be  accomplilhed.  It  often  happens, 
indeed,  unlefs  a  tolerable  degree  of  force  is  employed, 
that  bougies  will  not  pafs,  and  no  benefit  will  therefore 
be  derived  from  them  ;  for  unlefs  they  are  made  tq 
pafs  the  point  of  obftruction,  they  cannot  operate  widi 
advantage. 

This,  I  muft  obferve,  is  a  point  of  much  importance, 
and  ought  to  be  kept  in  view.  For  although  no  un- 
neceffary  force  fhould  be  ever  employed,  yet  we  com- 
monly meet  with  too  much  timidity  j  for,  in  ordinary 
practice,  if  the  bougie  meets  with  unufual  refiftance, 
and  if  it  cannot,  on  the  firft  or  fecond  attempt,  be  in- 
troduced, the  cafe  is  commonly  confidered  as  defper- 
ate,  and  no  further  trials  are  made.  I  can  from  much 
experience,  however,  fay,  that  few  cafes  occur,  in 
which  bougies,  by  a  frequent  repetition  of  cautious 
trials,  may  not  be  introduced.  Even  where  I  have 
been  convinced  that  the  paftage  of  the  urethra  has  at 
a  particular  point  been  entirely  obliterated  by  the  fides 
of  it  adhering  to  each  other,  and  where  the  urine  has 
long  been  voided  by  openings  in  the  perin^sum,  the 
bougie,  with  a  due  degree  of  force  properly  applied, 
has  at  laft  proved  fuccefsful. 

In  fome  inftances,  bougies  with  fmall  points  will 
pafs,  when  others  of  a  larger  fize  will  not  penetrate  ; 
but,  in  general,  when  the  obftruciion  is  found  to  be 
unufually  firm,  thofc  of  a  middling  fize  are  preferable 
to  fuch  as  have  fmall  points  :  for  bougies  of  this  form 
are  apt  to  bend  if  thay  do  not  pafs  forward  at  once  j 
and  as  foon  as  the  point  vields  in  any  degree,  the  bou- 
gie ftiould  be  withdrawn,  as  it  cannot  afteivv^ards  be 


254  ObJIruaions  in  Chap.  XXXIL 

pufhed  forward  ;  for  if  more  force  is  employed,  in- 
ftead  of  being  carried  farther  into  the  urethra,  it  be- 
comes twifted,  and  excites  pain  in  the  extraftion.* 

By  different  cautious  trials,  the  bougie  will  for  the 
mofl  part  be  made  to  pafs  the  different  points  of  ob- 
ftru6lion  ;  and  this  being  done,  as  bougies  have  fome- 
times  flipped  entirely  into  the  urethra,  and  even  into 
the  bladder  itfelf,  this  ought  to  be  carefully  guarded 
againft,  by  a  piece  of  cotton  thread  connected  with  the 
extremity  of  the  bougie,  being  either  tied  round  the 
penis  behind  the  glans,  or  to  a  circular  belt  pafled 
round  the  body. 

Certain  regulations  have  been  held  forth  by  authors 
for  the  time  that  bougies  fhould  be  kept  in  the  ure- 
thra :  but  with  fome  patients  they  excite  a  good  deal 
of  pain,  while  with  others  they  give  little  or  none  ; 
and  as  it  is  the  degree  of  pain  that  they  induce  which 
ought  to  regulate  the  time  that  they  remain  in  the  ure- 
thra, nothing  decifive,  it  is  evident,  can  be  faid  with 
refpeft  to  it.  When  they  excite  much  pain,  they 
ihould  neither  be  allowed  to  remain  long  at  once,  nor 
fhould  they  be  ufed  above  once  in  two  or  three  days : 
but  when  they  can  both  be  eafily  introduced  and  re- 
tained in  the  urethra,  they  fhould  be  inferted  often  ; 
for  as  it  is  by  their  preffure  alone  that  they  prove  ufe- 
ful,  and  as  this  mufi  be  continued  for  a  certain  length 
of  time,  according  to  the  caufe  of  the  obftruftion,  the 
more  conftantly  the  bougie  is  ufed,  the  more  quickly 
a  cure  will  be  performed  ;  and  with  the  fame  view  it 
fhould  be  gradually  increafed  in  fize,  till  the  largelt 
can  be  inferted  that  the  urethra  will  admit. 

When  bougies  excite  irritation,  they  fliould  never 
be  employed  but  when  the  patient  can  confine  himfelf 
to  his  apartment ;  but  with  many  the  diltrefs  that  they 
induce  is  fo  inconfiderable,  that  they  can  walk  eafily 

•  with  a  view  to  give  more  firmnefs  to  bougies,  Mr.  Deafe,  an  inge- 
nious furgeon  of  Dublin,  recommends  their  being  formed  upon  catgut. 
Vide  Obfervations  on  the  diflfcrent  Method*  of  treating  the  Vcucreal  Dif- 
cafe,  by  WiUiam  Dcale,  Dublin. 


Chap.  XXXII.  the  Urethra,  255 

with  bougies  of  the  largefl:  fize  inferted  along  the  whole 
courfe  of  the  urethra.  I  always  advife,  however,  the 
patient  to  remain  at  reft  while  a  bougie  is  in  the  ure- 
thra. 

Nothing  certain  can  be  faid.  of  the  length  of  time 
that  bougies  fliould  be  ufed,  as  this  muft  be  always 
regulated  by  their  effects  ;  which,  again,  will  in  a  great 
meafure  depend  on  the  nature  of  the  obftrudion. 
This,  however,  I  can  with  freedom  propofe,  that  they 
(hould  be  continued,  not  only  while  any  difficulty  in 
paffmg  water  remains,  but  for  a  confiderable  time 
thereafter. 

In  the  ufe  of  bougies,  care  fhould  be  taken  not  ta 
pufh  them  into  the  bladder  :  for,  even  when  prepared 
of  the  beft  materials,  a  portion  of  the  compofition  may 
crack  and  fall  off ;  and  if  this  (hould  not  pafs  off  with 
the  urine,  it  may  be  the  caufe  of  much  diftrefs,  by 
ferving  as  a  nucleus  for  a  ftone. 

Flexible  catheters  of  various  kinds  have  been  in- 
vented for  the  purpofe  of  remaining  in  the  urethra, 
and  for  anfwering  both  the  intention  of  catheters  and 
bougies.  Various  methods  of  forming  thefe  inftru- 
ments  have  been  propofed  ;  but  the  moft  convenient 
of  any  that  I  have  feen,  is  either  a  tube  of  relina  elaf- 
tica,  or  one  of  flexible  filver  wire,  wrapped  fpirally 
round  a  fteel  probe  of  a  proper  length  and  thicknefs  ; 
and  this  being  neatly  covered  with  fine  linen  fpread 
with  bougie  plafter,  and  the  probe  upon  which  it  was 
formed  being  withdrawn,  the  inftrumcnt  is  thus  com- 
pleted ;  only  it  muft  be  afterwards  furnifhed  with  a 
filver  wire  or  cleanfer,  in  a  fmiilar  manner  with  other 
catheters.  Thefe  inftruments,  however,  do  not  prove 
fo  ufeful  as  was  once  expected  ;  but  when  it  is  ever 
neceffary  to  allow  a  catheter  to  remam  long  in  the 
urethra,  one  of  this  flexible  form  anfwers  the  purpofe 
exceedingly  well.  It  muft,  however,  be  remembered, 
that  as  thefe  catheters  are  covered  with  plafters,  they 
fhould  not  be  allowed  to  remain  long  in  the  bladder. 


^5^  Objlruaions  in  Chap.  XXXIL 

for  the  fame  reafon  that  bougies  ought  not  to  be  in- 
ferted  into  it.  When  it  is  neceflary  to  leave  a  flexi- 
ble catheter  in  the  bladder,  thofe  that  are  compofed 
of  refina  elaflica  fliould  be  employed,  as  the  adhefive 
property  of  this  fubflance  prevents  it  from  cracking 
and  falling  off,  as  plaflers  of  every  kind  very  com- 
monly do. 

When  fpeaking  of  the  formation  of  bougies,  I  have 
faid,  that  as  it  is  chiefly  by  mechanical  preffure  they 
prove  ufeful,  fo  a  proper  confiftence  is  the  principal 
circumfl:ance  to  be  kept  in  view  in  their  compofition. 
This,  I  mufl;  again  fay,  fliould  be  our  leading  objeft 
in  the  employment  of  bougies  :  but  when  there  is  rea- 
fon to  think  that  chancres,  or  venereal  .ulcerations, 
exifl:  in  any  part  of  the  urethra,  as  nothing  would 
cicatrife  the  ulcers  fo  quickly  as  a  local  application  of 
mercury,  a  large  proportion  of  quickfilver  extinguifli- 
ed  in  honey  may  with  advantage  be  added  to  the 
compofition,  as  in  the  formula  given  above.  No.  5. 
As  mercury  in  this  fl:ate  excites  little  or  no  irritation, 
it  may  be  ufed  with  freedom.  Red  precipitate  in  fine 
powder  has  alfo  been  advifed  as  a  proper  ingredient 
in  bougies,  not  only  to  be  applied  in  this  manner  to 
ulcers  in  the  urethra,  but  with  a  view  to  corrode  oth- 
er caufes  of  obfl:ruction  :  this,  however,  is  a  practice 
that  ought  to  be  laid  afide,  as  the  precipitate  is  very 
apt  to  fl;imulate  and  inflame  the  membrane  of  the 
urethra. 

I  have  thus  entered  fully  into  the  confideration  of 
the  ufe  of  bougies.  Indeed,  too  much  attention  can- 
not be  given  to  a  praftice  from  which  fuch  important 
advantages  may  be  derived  :  for  by  a  proper  applica- 
tion of  bougies,  almofl:  every  caufe  of  obfl:ruci:ion  that 
I  have  enumerated  may  be  either  cured,  or  at  leaft 
greatly  relieved ;  and  were  it  not  for  the  advantages 
derived  from  bougies,  almofl:  every  cafe  of  ob(lru6;ion 
would  terminate  in  the.  moil  complete  degree  of 
mifery. 


Chap.  XXXII.  ihe  XJtethr.a.  257 

Before  concluding  the  fubject,  I  mud  not  omit  to 
mention  the  effed  of  bougies  in  fome  cafes  of  trouble- 
fome  gleets.  Whenever  this  kind  of  difcharge  is  kept 
up  by  an  excoriation  or  flight  ulceration  of  the  ure- 
thra, or  by  any  of  the  common  caufes  of  flridure,  as 
is  fometimes  the  cafe,  no  remedy  proves  fo  effeftual  as 
bougies  ;  and  even  in  ordinary  cafes  of  gleet,  proceed- 
ing from  a  relaxed  flate  of  the  excretory  duds  open- 
ing into  the  urethra,  nothing  proves  more  certain- 
ly ufeful  than  the  compreflion  induced  by  bougies. 
Whether  they  operate  by  affording  fupport  to  the  re- 
laxed membrane  of  the  urethra,  or  by  inducing  fome 
degree  of  inflammation  upon  the  parts  affetted,  1  know 
not ;  but  in  many  inltances  of  obilinate  gleet,  bougies 
have  been  found  to  anfwer,  when  other  remedies  have 
failed. 

Hitherto  I  have  confidered  obflruftions  of  the  ure- 
thra in  male  fubjeds  only ;  but  the  fame  difeafe  alfo 
occurs  in  women :  even  in  females,  bougies  are  oftea 
ufed  with  advantage ;  but  in  women,  tumors  of  fuch 
a  fize  fometimes  form  in  the  urethra,  as  cannot  pofli- 
bly  be  cured  by  this  remedy ;  and  as  the  urethra  iti 
females  is  not  only  fhort,  but  much  wider  than  in 
men,  thefe  tumors  may  in  them  be  often  removed, 
either  with  ligatures  or  with  the  fcalpel.  Nay,  we 
know  from  experience,  that  a  tumor  adhering  even  to 
the  bladder  itfelf,  may,  in  women,  be  taken  off  with 
fafety.  In  fuch  cafes,  there  is  a  neceffity  for  laying 
the  urethra  open ;  which  may  be  done  at  either  of  the 
fides,  and  without  any  rifk  of  wounding  the  vagina ; 
and  if  an  incifion  is  here  made  with  freedom,  any  tu- 
mor fituated  even  near  to  the  neck  of  the  bladder, 
may  be  fo  far  pulled  down  as  to  admit  of  the  applica- 
tion of  a  ligature ;  and  whenever  this  "can  be  done, 
the  attempt  may  be  made  without  hazard. 

A  remarkable  inftance  of  this  is  related  by  Mr, 
Warner,  where  a  tumor  of  the  fize  of  a  turkey's  ^^^^ 
produced  from  the  internal  membrane  of  the  bladder. 

Vol.  III.  S 


258  OhJlruEl'iom  In        Chap.  XXXII* 

was  extirpated  with  a  ligature,  and  with  mofl  com- 
plete fuccefs.*  When  fuch  tumors  are  not  fo  large  as 
totally  to  ob(lru£l  the  urine,  or  to  be  productive  of 
much  dillrefs,  a  prudent  practitioner  would  rather  de- 
cline to  meddle  with  them.  But  when  the  reverfe  of 
this  is  the  cafe,  and  when  the  urine  is  paffed  with  dif- 
ficulty, neceflity  points  out  the  propriety  of  this  ope- 
ration ;  and  it  mufl  be  comfortable  for  a  patient,  in  a 
fituation  that  would  otherwife  be  defperate  indeed,  to 
know  that  a  remedy  can  with  fafety  be  employed  from, 
which  a  cure  may  be  obtained. 

It  has  been  advifed  even  by  practitioners  of  reputa- 
tion, when  obftructions  of  the  urethra  proceed  from 
caruncles,  or  carnofities,  as  they  are  termed,  to  deflroy 
them  with  lunar  cauftic ;  and  inftruments  have  been 
invented  for  applying  the  caufhic  to  the  difeafed  parts, 
Plate  CXV.  jfigs.  i.  2.  and  3  :  but  the  rifk  of  injuring 
the  contiguous  parts,  even  when  the  cauftic  is  guard- 
ed in  the  mod  cautious  manner,  is  evidently  fo  great, 
as  muft  for  ever  prevent  the  pradtice  from  getting  in- 
to general  ufe. 

This  I  flill  venture  to  predict,  notwithftanding  all 
that  has  been  faid  by  Mr.  Everard  Home  in  recom- 
mendation of  the  ufe  of  cauftic  :  Mr.  Home  has  no 
doubt  removed  obftruCtions  in  the  urethra  with  cauf- 
tic ;  but  he  has  fo  frequently  failed,  after  putting  pa- 
tients to  fevere  pain,  and  after  the  moft  complete  tri- 
als were  given  to  his  plan,  that  wherever  it  has  fuc- 
ceeded,  I  have  much  reafon  to  believe  that  due  perfe- 
verance  in  the  ufe  of  common  bougies  would  have 
anfwered  equally  well ;  while  no  rifk,  and  not  the 
twentieth  part  of  the  pain,  would  have  been  the  effeCl 
of  their  application :  the  cleareft  proof,  indeed,  that 
can  be  given  of  the  inefficacy  and  danger  of  the  ufe 
of  cauftic  in  obftruCtions  of  the  urethra,  is  obtained 
J|"om  its  having  been  laid  afide  after  being  put  fully 

^  Vide  Cafca  and  Remarks  io  Surgery,  by  Jofeph  Warner. 


Chap*XXXn.  the  Urethra,  259 

to  the  tefl:  of  experience  more  than  a  century  ago,  as 
well  as  from  the  practice  being  ftill  confined  almoft 
entirely  to  the  hands  of  Mr.  Home ;  no  praditioner 
of  experience  of  whom  I  have  heard,  either  in  Lon- 
don, here,  or  elfewhere,  having  been  induced  to  adopt 
it,  after  all  the  trials  that  have  been  made  with  it : 
this  I  have  been  led  to  fay  from  the  baneful  influence 
which  I  have  much  reafon  to  believe  would  refult 
from  the  ufe  of  cauftic  in  difeafes  of  the  urethra,  were 
the  pradice  ever  to  be  generally  adopted  ;  and  I  fpeak 
to  its  inefficacy,  not  from  doubtful  fpeculation,  but 
from  ample  experience. 


S  Z 


1 


t6<y  Of  the  Fiftula      •  Chap.  XXXIII. 

CHAPTER     XXXIII. 

OF    THE    FISTULA    IN    PERIN^O, 


BY  the  term  fiftula  in  perinsco  is  meant,  a  finuou* 
ulcer  of  this  part,  communicating  moft  frequent- 
ly with  the  urethra  only,  but  in  fome  inftances  direct- 
ly with  the  body  of  the  bladder.  The  term,  however, 
is  not  fhridlly  confined  to  this  acceptation  ;  for  it  is  al- 
fo  applied  to  fome  ulcers  of  this  part  that  communi- 
cate with  the  fcrotum  and  penis. 

The  term  fiflula  fliould  with  propriety  be  reftrifted 
to  that  variety  of  fmus  in  which  the  edges  of  the  fore 
have  become  hard  and  callous  ;  but  cuftom  now  ap- 
plies it  indifcriminately  to  every  ulcer  that  is  not  fuper- 
ficial,  but  which  lies  deep,  and  difcharges  its  contents 
by  one  or  more  narrow  openings  in  the  external  teg- 
uments. 

In  confequence  of  the  latitude  given  to  the  mean- 
ing of  the  term  fiftula,  many  appearances  are  exhibit- 
ed under  this  general  denomination  of  fiftula  in  peri- 
naeo.  In  fome,  a  fingle  opening  is  met  with  in  the 
teguments  of  the  peringeum  or  penis,  difcharging  mat- 
ter mixed  with  urine  :  this,  in  fome  inftances,  is  not 
pven  accompanied  with  hardnefs  or  inflammation  of 
the  contiguous  parts,  but  in  others,  inftead  of  this 
fimple  form  of  the  difeafe,  along  with  one  or  more  ex- 
ternal openings  communicating  with  the  urethra,  at 
which  all,  or  at  leaft  the  greateft  part,  of  the  urine  is 
pafTed,  the  parts  contiguous  to  thefe  openings  are 
much  difeafed.  In  fome  they  are  found  merely  hard 
or  callous,  without  much  enlargement ;  but  in  others 
they  are  not  only  hard,  but  much  fwelled,  inflamed, 
and  painful.  In  a  fev/,  this  hardnefs  and  enlargement 
is  confined  to  a  fmall  fpace ;  but  moft  frequently. 


Chap.  XXXIII.  in  Perlnao,  s6i 

when  the  difeafe  has  been  of  long  continuance,  it  ex- 
tends nearly  from  the  anus  to  the  fcrotum,  reducing 
the  whole  perina^um  to  a  ftate  of  callofity.  In  many, 
the  malady  does  not  ftop  here  :  the  fcrotum,  and  even 
the  penis,  becomes  difeafed ;  and  when  the  urine  at 
laft  efcapes  into  the  cellular  fubftanCe  of  thefe  parts, 
particularly  when  it  lodges  in  the  fcrotum,  it  never 
fails  to  excite  a  great  deal  of  mifchief. 

In  confidering  this  difeafe,  the  caufes  by  which  it 
may  be  produced,  firft  merit  attention.  They  are  in 
general  as  follow : 

1.  AVounds  and  other  injuries  of  the  urethra  and 
bladder,  in  whatever  manner  they  may  be  produced. 

In  the  old  method  of  performing  lithotomy  by  the 
apparatus  major,  the  parts  were  fo  much  bruifed  and 
lacerated,  that  the  wound  feldom  healed  kindly,  and 
frequently  became  fillulous ;  but  when  the  operation 
is  well  performed,  according  to  the  prefent  improved 
method,  this  feldom  happens.  From  fome  caufe  or 
other,  however,  it  happens  in  a  few  inflances,  that  the 
urine  does  not  flow  freely  by  the  penis  ;  and  finding 
a  ready  pafl'age  by  the  wound,  it  continues  to  come 
off  in  this  manner,  till  the  edges  of  the  fore  becoming 
callous,  the  difeafe  in  queftion  is  produced.  In  fome, 
a  direft  communication  is  kept  up  between  the  neck 
of  the  bladder  and  the  fore ;  but  in  others,  the  urine 
paffes  firfl  into  the  urethra,  and  from  thence  is  dif- 
charged  by  the  wound  in  the  perinasum. 

Filtulous  openings  are  fometimes  the  confequence 
of  incifions  made  into  the  urethra,  for  the  purpofe  of 
extrading  (tones  that  lodge  in  it. 

2.  Inflammation  in  any  part  of  the  urethra,  by 
whatever  caufe  it  may  be  induced,  if  it  terminates  in 
an  abfcefs,  is  very  apt  to  corrode  the  membrane  of 
this  canal,  and  to  produce  a  fmuous  opening,  at  which 
the  urine  is  difcharged.  This,  I  may  remark,  is  not 
an  unfrequent  confequence  of  virulent  gonorrhoea : 
for  wh^n  the  infiammation  fprcads  along  the  perinse- 
um  towards  the  anus,  if  it  be  not  quickly  removed  by 


262  Of  the  Fijiula        Chap.  XXXIII. 

bloodletting,  and  fuch  other  means  as  are  employed, 
it  is  very  apt  to  terminate  in  fuppuration. 

Abfcefles  that  form  originally  in  the  foft  parts  about 
the  anus,  are  alfo  known  to  give  rife  to  it,  by  exciting 
inflammation  and  ftriclure,  terminating  in  fuppuration, 
in  the  cellular  fubftance  connefted  v^^ith  the  urethra. 

3.  The  feveral  caufes  enumerated  in  the  laft  Chap- 
ter inducing  obftruftion  of  the  urethra,  by  impeding 
the  free  difcharge  of  the  urine,  frequently  give  rife  to 
the  difeafe  now  under  confideration  ;  and  according- 
ly we  find  that  fiflulous  fores  in  the  perinseum  are 
very  commonly  connected  with  an  obftructed  Hate  of 
the  urethra. 

As  the  difeafe  may  thus  be  induced  by  various  cau- 
fes, it  is  neceffary  to  have  thefe  in  view  in  the  courfe 
of  the  cure.  In  order,  however,  to  render  this  very 
perplexing  branch  of  practice  as  obvious  and  fimple 
as  poffible,  it  is  necelfary  to  remark,  that  the  diS'erent 
caufes  that  I  have  enumerated,  tend  to  the  produdion 
of  the  difeafe  by  two  general  effefts  only : 

1.  By  the  formation  of  a  paffage  dire6lly  into  the 
urethra  or  bladder,  either  by  external  violence,  or  by 
the  deftruclion  of  part  of  the  membrane  of  the  ure- 
thra, as  a  confequence  of  ulcers  feated  in  it,  or  of  mat- 
ter colleded  in  abfcelfes  tending  to  abrade  i^s  fub- 
ftance ;  this,  we  fuppofe,  may  occur,  independently 
of  any  obftruction  to  the  paifage  of  the  urine. 

2.  By  the  fole  influence  of  obftructions  in  the  urci- 
thra :  thefe,  by  putting  a  ftop  to  the  free  evacuation 
of  urine,  at  firfl  induce  a  fulnefs  and  tenfion  of  the 
urethra,  which,  if  not  quickly  removed,  very  com^ 
nionly  terminates  in  a  complete  rupture  of  this  canal. 

In  the  treatment,  therefore,  of  this  difeafe,  we  are 
to  be  directed  by  one  or  other  of  thefe  general  effects  ; 
and  it  is  to  be  remarked,  that  in  no  difeafe  is  it  of 
more  importance  to  difliinguifli  accurately  between  the 
caufes  by  which  it  is  induced.  When  the  opening  in 
the  urethra  has  been  produced  by  previous  obftrucr 
tion,  no  external  application,  nor  any  remedy  diredt« 


Chap.  XXXIII.  in  Pcrinae.  263 

ed  to  the  fyflem,  will  have  any  efFed ;  while  a  proper 
and  long  continued  ufe  of  bougies,  by  removing  the 
obftruftion,  will  feldom  fail.  And,  on  the  other  hand, 
when  the  difeafe  has  not  originated  from  obftrudion, 
but  has  been  induced  by  a  fimple  opening  in  the  ure- 
thra, bougies  are  not  only  very  unneceflary,  but  fre- 
quently do  harm.  This,  I  muft  obferve,  is  a  diftinc- 
tion  not  fufficiently  attended  to  in  pradice.  Affec- 
tions of  this  kind  are  commonly  treated  with  bougies 
only,  whatever  may  have  been  the  caufe  by  which 
they  were  induced  ;  but  we  (hall  foon  make  it  appear 
that  this  muft  frequently  be  wrong. 

In  the  cure  of  hftulous  fores  of  thefe  parts,  it  is  a 
matter  of  the  firft  importance  to  diftinguifh  between 
fuch  as  are  merely  local,  and  thofe  that  are  connedted 
with  any  general  difeafe  of  the  fyftem.  For  however 
well  our  means  of  cure  might  be  direded  to  the  topi- 
cal management  of  the  fores,  if  the  patient  at  the  fame 
time  laboured  under  lues  venera,  fcrofula,  or  fcurvy, 
no  permanent  cure  could  be  expeded,  if  the  difeaf<j 
of  the  conftitution  were  not  to  be  removed. 

Where  a  filtulous  fore  is  produced  by  ftridlures  ii^ 
the  urethra,  bougies  is  the  only  remedy  we  can  truft  j 
and  when  properly  applied,  they  very  commonly  fuc- 
ceed.  They  ought  to  be  continued  till  the  ftridures 
are  entirely  removed,  when  the  urine  being  freely  and 
eafily  paffed,  the  fores  which  the  ftrictures  had  induc- 
ed, very  commoly  heal ;  but  when  they  do  not  heal, 
the  cure  is  for  the  moft  part  found  to  be  checked  by 
the  edges  of  the  fores  having  become  hard  or  callous ; 
and  till  this  ftate  of  the  parts  is  removed,  no  progrefs 
towards  amendment  is  to  be  looked  for. 

We  are  therefore  to  deftroy  thefe  callous  edges  of 
the  fore,  as  foon  as  it  is  found  that  the  bougies  do  not 
fucceed  ;  and  the  method  of  doing  it  this  :  the  patient 
muft  be  laid  upon  a  tiible,  in  nearly  the  fame  pofture 
as  in  the  operation  of  lithotomy  ;  and  a  ftaff  being  in- 
troduced into  the  urethra,  and  made  to  pafs  the  open- 
ing at  which  the  urine  is  difcharged,  it  is  in  this  fitua- 


264  Of  the  Fijiula        Chap.  XXXIII. 

tion  to  be  held  firm  by  an  affiflant ;  while  the  furge- 
on,  introducing  a  fmall  probe  or  diredor  at  the  exter- 
nal opening  of  the  fore,  and  cutting  upon  it  in  the  di* 
reOiion  of  the  finus,  is  thus  to  lay  it  open  through  its 
whole  length,  till  it  terminates  either  in  the  urethra, 
or,  if  neceffary,  in  the  bladder  itfelf. 

When  more  fmufes  than  one  are  difcovered,  they 
muft  all  be  laid  open  in  the  fame  manner.  In  fome 
inftances,  we  meet  with  difl'erent  fmufes  in  the  cellu- 
lar membrane,  leading  from  one  opening  in  the  ure- 
thra ;  while,  in  others,  there  are  as  many  openings  in 
the  urethra  as  external  fores  or  finufes.  This,  howev- 
er, is  uncommon :  but  this  is  not  a  matter  of  import- 
ance, as  the  fame  method  of  treatment  anfwers  equal- 
ly well  in  both  j  for  whether  the  different  fmufes  orir 
ginate  from  one  common  opening  in  the  urethra,  or 
not,  they  ought  all  to  be  laid  open  from  one  end  to 
the  other. 

In  general,  this  fimple  divifion  of  the  fmufes  would 
prove  fufficient ;  but  when  any  of  the  parts  through 
which  they  run,  have  become  uncommonly  hard,  a 
fmall  portion  of  the  difeafed  parts,  contiguous  to  the 
fores,  Ihould  be  removed  with  the  fcalpel.  This,  how- 
ever, is  not  always  neceifary,  as  the  inflammation  and 
confequent  fuppuration,  induced  by  the  mere  divifion 
of  the  fmus,  very  commonly  removes  every  flight  de- 
gree of  callofity  ;  but  when  the  hardened  parts  are  ex- 
tenfive,  and  too  coniiderable  to  be  removed  in  the 
courfe  of  the  fubfequent  fuppuration,  fuch  a  propor^ 
tion  of  them  fhould  be  cut  off  with  the  fcalpel,  as  might 
not  probably  be  removed  in  this  manner.  This,  how- 
ever, is  a  point  on  which  nothing  decifive  can  be  faid  ; 
for  the  neceflity  of  removing  a  portion  of  thefe  difea- 
fed parts,  and  the  quantity  to  be  removed,  mufl:,  in  all 
fuch  cafes,  be  left  to  the  judgment  of  the  operator. 

After  all  the  fmufes  have  been  freely  divided,  the 
{lafF  fliould  be  withdrawn,  and  the  divided  parts  gentr 
ly  feparated,  by  the  introdudion  of  foft  lint  fpread 
with  any  emoUient  ointment,  in  order  to  prevent  theiy 


Chap.  XXXIII.  in  Pcrlnao.  16^ 

immediate  reunion.  But  although  fome  eafy  applica- 
tion fnould  for  this  purpofe  be  inferted  between  the 
lips  of  the  wound,  it  ought  to  be  done  with  caution  ; 
for  {luffing  or  cramming  the  fores,  as  is  fometimes 
done,  always  does  harm,  and  often  renders  all  the  oth- 
er fteps  of  the  operation  abortive.  The  fores  are  now 
to  be  covered  with  a  pledget  of  emollient  ointment ; 
and>proper  compreffes  being  applied  over  it,  the  T 
ban^ge  fliould  be  employed  to  retain  them. 

About  twenty-four  hours  after  the  operation,  the 
outward  coverino^s  fliould  be  removed,  and  an  emol- 
lient  poultice  applied  over  the  dreffings  ;  and  as  foon 
as  a  free  fuppuration  has  taken  place,  the  whole  fliould 
be  removed,  and  light  eafy  dreilings  continued  till  the 
fores  are  healed,  by  a  proper  adhefion  of  the  parts  at 
the  bottom  of  each. 

A  very  important  part  of  the  cure  is  found  to  con- 
fift  in  the  dreffings  being  duly  applied.  Indeed,  reg- 
ular dreffings  are  of  fuch  importance,  that,  without 
this  attention,  all  the  previous  fteps  of  the  operation 
avail  nothing.  It  is  chiefly,  indeed,  by  more  attention 
being  given  to  this  in  private  praQ:ice,  than  can  eafily 
be  done  in  hofpitals,  that  we  prove  more  fuccefsful 
with  private  patients  in  the  treatment  of  fores  of  this 
defcription. 

I  have  not  yet  mentioned  the  ufe  of  bougies,  nor  of 
the  catheter,  as  a  necefl'ary  part  of  the  treatment  fub- 
fcquent  to  the  operation ;  and  in  this  I  fliall  pcffibly 
appear  to  be  Angular  ;  for  we  are  commonly  advifed 
to  keep  a  bougie  confl:antly  inferted  from  the  time  of 
the  operation,  excepting  at  the  time  of  voiding  urine, 
when  a  catheter  is  advifed  to  be  employed  ;  and  in 
order  to  avoid  the  trouble  of  withdrawing  the  one, 
and  inferting  the  other,  fome  praditioners  advife  a 
flexible  catheter  to  be  kept  in  the  urethra  from  the 
firft. 

The  advantages  fuppofed  to  accrue  from  the  ufe  of 
bougies  here,  is  the  prevention  of  any  undue  contrac- 
tion of  the  urethra  j  and  by  the  catheter  it  is  meant 


a66  Of  the  Tijlula        Chap.  XXXIII. 

to  prevent  the  urine  from  pafllng  off  by  the  fore  dur- 
ing the  cure.  Thefe  motives,  for  ufmg  both  the  one 
and  the  other,  are  plaufible  ;  and  they  have  accord- 
ingly been  generally  adopted.  I  am  free  to  confefs, 
too,  that,  following  the  example  of  others,  I  have  oft- 
en employed  both  the  catheter  and  bougie  ;  but  I  can- 
Bot  fay  that  I  ever  did  fo  with  advantage,  and  I  have 
often  feen  them  do  much  harm.  By  diftending  the 
urethra,  the  fores  do  not  fo  readily  heal ;  and  if  the 
Catheter  does  not  pafs  fully  into  the  bladder,  part  of 
the  urine,  in  coming  off,  almoil  conftantly  paffes  be- 
tween it  and  the  urethra,  fo  as  to  get  accefs  to  the 
wound,  by  which  it  does  more  harm  to  the  fore,  than 
if  no  catheter  had  been  ufed  :  and,  again,  if  a  cathe- 
ter is  paffed  entirely  into  the  bladder,  and  kept  long 
in  this  fituation,  it  almoft  conftantly  does  harm,  by 
inducing  pain,  inflammation,  and  fwelling  about  the 
neck  of  the  bladder. 

But  whoever  will  go  freely  into  a  different  practice, 
and  will  endeavour  to  cure  this  kind  of  fore  without 
the  aid  of  thefe  inftruments,  will  foon  find  that  they 
are  not  neceffary  ;  and  that  the  wound  in  the  urethra, 
from  the  operation  that  I  have  defcribed,  is  in  general 
more  eafily  cured,  without  the  affiftance  either  of  bou- 
gies or  catheters,  than  when  they  are  employed ;  for 
inftead  of  forwarding  the  cure  of  the  fore,  they  uni- 
formly tend  to  retard  it,  by  tearing  open  fuch  adhe- 
fions  as  nature,  if  left  to  herfelf,  would  have  made  al» 
together  complete. 

This,  I  muft  again  remark,  is  a  point  of  much  im- 
portance, and  merits  all  poffible  attention.  The  ufe 
of  the  bougie,  in  all  fuch  cafes,  is  at  prefent  fo  univer* 
fal,  that  the  cure  of  a  fiftula  in  perinseo  by  an  opera- 
tion, is  almoft  never  attempted,  but  where  bougies  are 
at  the  fame  time  employed  ;  but,  from  much  experi- 
ence in  this  branch,  I  am  now  convinced  that  many 
more  would  be  cured,  if  the  bougie  and  catheter  were 
Jooth  laid  afide. 


Chap.  XXXIII.  in  Perinao.  aSy 

In  real  obftruclions  of  the  urethra,  bougies,  as  I 
have  faid,  are  almofl:  the  only  remedy  to  be  trufted  ; 
but  they  are  of  no  farther  ufe  after  thefe  obftruclions 
are  deftroyed  :  when,  therefore,  a  fiftulous  opening 
remains  after  the  obftruftions  are  removed,  or,  when 
no  ftrifture  or  obftrudion  exifts,  the  operation  that  I 
have  defcribed  ought  alone  to  be  depended  on ;  and 
in  this  part  of  the  cure  bougies  ought  never  to  be  em- 
ployed. 

But  it  is  faid  by  thofe  who  patronife  the  ufe  of  the 
bougie  and  catheter,  that  if  the  urine  is  allowed  to  pafs 
out  by  the  fore,  the  cure  will  be  thereby,  if  not  alto- 
gether prevented,  at  leaft  much  retarded.  To  this  it 
may  be  anfwered,  that  after  the  operation  of  lithoto- 
my, we  do  not  find  the  cure  retarded  although  the 
urine  comes  at  all  times  into  immediate  contaft  with, 
and  during  the  firft  days  after  the  operation  pafles  con- 
ftantly  off  by  the  wound.  In  what  manner  this  is  ef- 
fected, I  fhall  not  at  prefent  determine  ;  but  that  the 
fad  is  fo,  no  pradlitioner  will  deny  :  and  from  all  the 
experience  that  I  have  had,  openings  in  any  other  part 
pf  the  urethra,  require  no  more  ailiftance  from  bou- 
gies or  catheters,  than  they  do  in  that  part  of  it  which 
is  divided  in  lithotomy  ;  and  every  lithotomift,  I  be- 
lieve, would  fpurn  at  the  idea  of  keeping  a  catheter 
conftantly  in  the  bladder  after  this  operation,  in  order 
to  prevent  the  urine  from  pafllng  off  by  the  wound. 

It  happens,  indeed,  in  a  few  cafes  of  lithotomy,  that 
a  contracted  ftate  of  the  urethra  is  produced  by  the 
cicatrix  of  the  fore  :  in  this  fituation,  after  the  parts 
are  firmly  united,  bougies  prove  fometimes  ufeful  by 
removing  the  ftridure  ;  and  in  particular  inltances, 
where  the  fore  does  not  heal,  by  the  urine  continuing 
to  pafs  by  the  wound,  in  confequence  of  ftridures  or 
adhefions  in  the  urethra,  the  bougie  is  employed  with 
advantage  even  during  the  progrefs  of  the  cure.  But 
thefe  arc  rare  occurrences,  and  no  practitioner  has  ev» 
er  recourfe  to  bougies,  till  fome  degree  of  obftrudion 


263  '  Of  the  Fijlula         Chap.  XXXIIL 

has  actually  taken  place-:  in  the  fame  manner  they 
iliould  never  be  employed  in  this  operation,  till  the 
propriety  of  ufmg  them  is  pointed  out  by  the  forma- 
tion of  fome  deijrce  of  obftrufticn. 

When  the  parts  of  which  the  perinasum  is  formed 
have  become  hard  and  otherwife  difeafed,  before  any 
operation  fuch  as  I  have  defcribed  is  advifed,  we  are 
commonly  directed  to  a  long  continued  ufe  of  poulti- 
ces ;  mercurial  fridions  ;  and  the  ufe  of  refolvent  gum 
plafters.  So  far,  however,  as  I  have  obferved,  Httle 
or  no  advantage  is  derived  from  this  ;  for  any  fuppu- 
ration  which  it  excites,  is,  in  general  partial,  io  that  it 
has  little  effe6t  in  removing  the  hardnefs  for  which  it 
was  employed. 

And,  again,  when  the  hardened  parts  are  extenfive, 
and  when  no  relief  is  obtained  from  the  difcutient 
remedies  that  I  have  mentioned,  we  are  in  general  ad- 
vifed to  cut  them  entirely  av/ay  with  a  fcalpel.  There 
is  no  neceffity,  however,  for  this  meafure  ;  for  al- 
though it  may  be  proper  to  remove  the  edges  of  the 
fores  when  they  have  become  callous,  there  is  never 
any  good  caufe  for  extirpating  all  the  difeafed  parts  : 
it  would  frequently  be  a  painful  and  cruel  operation  ; 
and  as  it  could  feldom  be  of  any  real  advantage,  it 
ought  rarely,  or  never  to  be  practifed. 

When,  again,  a  preternatural  opening  is  formed  in 
the  urethra,  either  by  external  violence  or  the  abrafion 
pf  its  fubftance  by  abfceffes  feated  in  it,  a  different 
courfe  of  treatment  becomes  neceffary.  When  pro- 
duced by  an  abfcefs  in  the  perin?2um,  or  in  any  part 
of  the  urethra,  a  free  difcharge  fhould  be  given  to  the 
matter ;  every  part  of  the  cellular  fubftance  in  which 
it  is  Jbund  to  lodge  {hould  be  laid  open  ;  and  warm 
fomentations  and  poultices  Ihould  be  applied  to  fuch 
inflammatory  tumors  as  have  not  fuppurated.  In  this 
manner,  fores,  which  if  negledled,  would  prove  high- 
ly diftrefsful,  are  often  made  to  heal  eafily  ;  but  when 
even  by  thefe  means  the  fores  do  not  unite,  and  con- 


Chap.  XXXin.  in  Perinao,  269 

tinue  to  difcharge  matter,  and  efpecially  when  their 
edges  become  hard  and  callous,  the  finufes  muft:  be 
laid  open,  and  every  other  part  of  the  cure  condudled 
in  the  manner  that  I  have  ah"eadv  advifed. 

This  kind  of  fore  when  produced  by  wounds  of  the 
urethra,  requires  a  fimilar  method  of  cure.  By  the 
removal  of  extraneous  matter,  and  by  the  ufc  of  poul- 
tices to  abate  inflammation,  a  cure  will  often  be  ac- 
compliflied  without  any  other  alliftance  ;  but,  when 
the  Itate  of  the  fores  requires  it,  they  ought  to  be  laid 
open,  and  treated  in  every  refped  like  other  cafes  oi 
fiftula. 

The  moft  diftrefsful  variety  of  this  kind  of  fore,  is 
that  in  which  the  urine  pafles  off  diredly  from  the 
body  of  the  bladder  without  communicating  with  the 
urethra.  This  variety  of  the  difeafe,  I  may  remark, 
is  readily  diftingu idled  from  the  other  by  the  urine 
drilling  off  infenfibly  and  at  all  times  ;  whereas,  when 
the  external  opening  does  not  communicate  direftly 
with  the  bladder,  and  when  the  urine  paffes  firit 
through  part  of  the  urethra,  the  patient  has  common- 
ly the  power  of  retention  in  full  perfection  ;  by  which 
his  fituation  is  much  more  comfortable  than  when  the 
urine  is  conftantly  paffmg  off.  But  although  this  va- 
riety of  the  difeafe  is  eafily  diftinguifhed  from  the  oth- 
er, it  is  not  fo  readily  cured  ;  for  the  fmufes  from 
whence  the  urine  is  difcharged  communicate  diredly 
witii .  the  bladder,  and  nothing  tends  to  remove  them 
but  laying  them  open  to  the  bottom. 

When,  therefore,  a  patient  diftreffcd  with  this  kind 
of  fore,  finds  his  fituation  to  be  fuch  as  to  make  the 
pain  and  rifk  of  fuch  an  operation  an  eligible  alterna- 
tive, it  ought  certainly  to  be  advifed,  as  the  only  means 
from  which  any  relief  is  ever  likely  to  be  derived. 

As  the  intention  and  principle  of  this  operation  are 
the  fame  as  of  that  in  which  the  urethra  only  is  con- 
cerned, all  that  need  be  faid  in  regard  to  the  mode  of 
performing  it  is,  that  a  fluff  fliould  be  introduced  into 


270  Of  the  Fi/iula  in  Pennao.     Chap.  XXXIIL 

the  bladder ;  the  different  fmufes  fhould  be  laid  free-" 
ly  open  to  the  bottom  ;  their  edges,  if  callous,  Ihould 
be  removed  to  fuch  a  depth  as  can  be  done  with  fafe- 
ty,  and  the  wounds  thus  produced  fliould  be  lightly 
dreffed,  in  the  manner  I  have  already  pointed  out. 

In  this  manner,  a  great  proportion  of  this  variety 
of  fore  may  be  cured,  provided  the  means  are  employ- 
ed in  due  time,  and  duly  perfifted  in  :  but  in  long 
continued  fillulous  fores  of  thefe  parts,  where  the  fur- 
rounding  cellular  membrane  has  become  much  hard- 
ened, and  otherwife  dil'eafed  ;  and  efpecially,  when 
the  fyftem  is  tainted  with  fcurvy,  fcrotula,  or  lues  ve- 
nerea ;  it  mufl  be  acknowledged  that  no  means  with 
which  we  are  acquainted  will  prove  at  all  times  fuc- 
cefsful. 


Chap.  XXXIV.       Of  Hemorrhoids^  l^c,  i-]\ 


CHxVPTER   XXXIV. 


pF    HAEMORRHOIDS,    OR    PILES. 


THE  term  hcEinorrhoids,  or  piles,  was  at  one  time 
applied  to  ever)^  evacuation  of  blood  from  the 
veins  running  upon  and  in  the  neighbourhood  of  the 
redum  ;  but  a  mere  diftcntion  of  thefe  veins,  when 
productive  of  pain,  now  receives  the  fame  denomina- 
tion. 

As  long  as  the  difeafed  parts  of  the  veins  remaii¥ 
diftendcd,  and  do  not  difcharge  any  part  of  their  con* 
tents,  the  piles  are  named  cascae  or  blind ;  but  whea 
they  burft  and  difcharge  blood,  they  are  termed  aperC 
or  open. 

It  frequently  happens,  that  a  difcharge  of  blood  ujv 
on  going  to  ftool  is  the  firft  warning  or  appearance  of 
this  difeafe  :  for  although  in  fome  inflances  it  is  oth- 
erwife,  yet  when  the  parts  of  the  veins  chiefly  affecled 
lie  high  in  the  reftum,  the  pain  or  uneafmefs  which 
they  excite  is  for  the  moft  part  inconfiderable,  owing 
to  the  veins  in  this  fituation  being  furrounded  with, 
parts  which  from  their  foftnefs  readily  yield  to  their 
diftention  ;  whereas,  when  the  difeafe  occurs  at  the 
end  of  the  gut,  as  the  inteftine  is  here  furrounded  with 
a  firm  mufcular  covering,  the  fpliindler  ani,  a  good 
deal  of  refiftancc  is  thereby  given  to  the  formation  o£ 
ha^morrhoidal  tumors,  and  they  accordingly  in  this 
fituation  almoft  always  excite  a  great  deal  of  diftrefs. 

When  piles  are  fo  fituated  as  to  be  within  view,  if" 
they  have  begun  to  dil'charge  blood,  one  or  more 
fmall  openings  are  obfcrved,  from  whence  the  blood 
is  poured  out :  when  the  parts  have  not  been  previ- 
oufly  much  diftendcd,  thefe  openings  appear  to  be  the 
mouths  or  outlets  of  veins  j  and  the  openings  from 


37a  Of  Hamorrhcids,      Chap.  XXXIV. 

whence  the  blood  proceeds,  are  each  of  them  obferv- 
ed  to  be  feated  upon  a  fmall  protuberance  arifing  from 
the  internal  coat  of  the  gut.  In  general,  thefe  tu- 
mors, when  they  difcharge  freely,  are  fmall,  being 
feldom  larger  than  an  ordinary  pea ;  but  when  any 
obftrudion  occurs  to  the  difcharge  of  their  contents, 
they  gradually  increafe,  till  in  Ibme  inftances  they 
arriv^e  at  the  fize  of  pigeons  or  pullets  eggs,  when  by 
the  pain,  irritation,  and  tenefmus,  which  in  fuch  a 
(late  they  always  excite,  much  diftrefs  and  mifery  are 
produced  by  them.  Even  when  the  tumors  at  lafl 
burft:  and  difcharge  their  contents,  if  they  have  previ- 
Gufly  become  large,  they  do  not  disappear  entirely  : 
on  the  contrary,  they  ftill  continue  of  nearly  the  fame 
fize  ;  they  aflume  a  livid  appearance  ;  and  inflcad  of 
being  foft  or  elaflic,  they  are  firm  and  of  a  flelhy  con- 
fiflence. 

As  long,  however,  as  hsemorrhoidal  tumors  remain 
fhut,  they  are  foft  and  yielding  to  the  touch,  infomuch 
that  by  preflure  they  can  commonly  be  much  dimi. 
nifhed  ;  their  colour  is  flill  more  livid  than  that  of  the 
apert  kind,  and  they  are  commonly  more  painful :  for 
although  they  do  not  ufually  become  large  before 
burfling ;  yet  when  they  lie  deep,  and  are  thickly 
covered  with  firm  unyielding  parts,  the  tumors  are  in 
fome  inflances  of  fuch  a  fize,  as  almoll  entirely  to  ob- 
ftrucl  the  pafliige  of  the  faeces  ;  and  as  a  tenefmus  is 
a  common  fymptom  in  this  flate  of  piles,  the  diftrefs 
produced  by  the  frequent  inclination  to  go  to  flool, 
together  with  the  difficulty  of  the  evacuation,  never 
fail  to  induce  a  great  deal  of  mifery. 

Thefe  tumors  have  commonly  been  fuppofed  to  pro- 
ceed from  a  mere  dilatation  of  the  hsemorrhoidal 
veins.  In  the  incipient  ftate  of  the  difeafe,  while  they 
remain  fmall  and  circumfcribed,  this  m.ay  frequently 
be  the  cafe ;  but  whenever  they  become  large,  they 
will  almofl  conftantly  be  found  to  be  connefted  with 
an  effufion  of  blood  into  the  contiguous  cellular  fub- 
itance. 


Chap.  XXXIV.     *       cr  Piles.  273 

As  long  as  piles  remain  fmall,  foft,  and  compeffif 
ble,  we  may  conclude,  that  the  blood  ftill  remains 
within  the  cavities  of  the  veins  ;  but  v.henever  they 
become  large,  and  of  a  firm  flefliy  confiftence,  the 
blood,  as  I  have  juft  obferved,  uill,  in  almofl  every 
inflance,  be  found  effufed  into  the  neighbouring  parts. 

Various  conjedures  have  taken  place  on  the  nature 
of  the  ha^morrhoidal  difcharge  :  but  the  mod  prevail- 
ing opinion  is,  that  it  is  commonly  of  a  critical  na- 
ture ;  that  it  is  induced  by  the  prefence  of  fome  pec- 
cant or  morbific  matter  in  the  fyftem  ;  and  that  there- 
fore it  would,  in  general,  be  improper  to  put  a  (top 
to  if. 

It  does  not,  however,  require  minute  inveftigatioa 
to  fhew,  that  this  reafoning  is  ill  founded  :  for  were 
we  even  to  allow,  that  the  piles  commonly  appear 
without  the  intervention  of  any  evident  occafional 
cacfe,  and  that  they  are  in  reality  connected  with  fome 
morbific  humor  in  the  blood,  in  what  manner  can  we 
fuppofe  this  difeafed  matter  to  be  feparated  and  dif- 
charged  by  the  htemorrhoidal  flux  ?  Now  that  the  cir- 
culation of  the  blood  is  well  underltood,  it  will  be  dif- 
ficult for  the  fupporters  of  this  opinion  to  give  a  fatif- 
faclory  anfwer  to  this  quedion.  But,  independent  of 
this,  we  know  that  piles  are  very  commonly  induced, 
perhaps  in  nineteen  cafes  of  twenty,  by  an  obvious 
caufe ;  and  that  the  removal  or  prevention  of  this, 
when  effeded  in  due  time,  almoft  conflantly  prevents 
or  cures  the  difeafe.  In  a  great  proportion  of  cafes, 
piles  will  be  found  to  proceed  from  compreffion  upon 
the  ha^morrhoidal  veins  ;  by  which  the  blood  contain- 
ed in  them  being  impeded  in  its  progrefs  to  the  heart, 
dilatations  of  thefe  veins,  and  fubfequent  efFufions,  are 
confequences  that  necellarily  enfue. 

The  moil  frequent  caufes  of  this  compreffion  are, 
large  collections  of  hard  faeces  in  tlie  redum  ;  the 
prefiure  produced  upon  the  neighbouring  parts,  in 

Vol.  III.  T 


^74  Of  Hanhdrrholds,         Chap.  XXXIV* 

pregnancy,  by  the  gravid  uterus  \  and  laRly,  tumors, 
of  whatever  nature  they  may  be,  which,  from  their 
fituation,  comprefs  the  hscmorrhoidal  veins.  Thus 
piles  are  not  an  unfrequent  effeQ:  of  fchirrous  tumors 
in  the  rectum,  and  of  fimilar  aifedions  of  the  proftate 
gland  and  bladder  ;  and  I  have  fometimes  traced  them 
as  the  confequence  of  fwellings  in  the  mefenteric 
glands,  which  alfo  a£t  by  obllructing  the  refluent  vef- 
fels  in  their  courfe  from  the  rectum. 

When  tumors  in  the  contiguous  parts  are  found  to 
produce  the  difeafe,  the  means  of  cure  muft  be  direft- 
ed  particularly  to  the  removal  of  thefe.  When  preg- 
nancy is  the  caufe,  gentle  laxatives,  and  a  frequent 
recumbent  pofture,  will  often  afford  relief;  but  noth- 
ing will  remove  the  difeafe  till  delivery  takes  place. 
And,  again,  when  piles  have  been  induced  by  coftive- 
nefs,  a  regular  ufe  of  gentle  aperients,  fuch  as  cream 
of  tartar  and  oil  of  caftor,  will  very  commonly  pro- 
cure relief.  But  when  the  parts  inflame  and  become 
painful,  fuch  remedies  muft  be  employed  as  are  known 
to  be  moft  powerful  in  removing,  or  even  preventing 
the  effects  which  thefe  fymptoms  ufually  induce.  If 
much  fever  prevails,  blood  fhould  be  difcharged  in 
proportion  to  the  ftrength  of  the  patient ;  and  it  an- 
fwers  beft  when  taken  by  means  of  leeches  applied  as 
near  as  poffible  to  the  feat  of  the  pain  :  nay,  I  often 
apply  them  upon  one  or  more  of  the  hjemorrhoidal 
tumors,  and  very  commonly  with  much  advantage : 
the  pained  parts  fhould  be  frequently  bathed  with  a 
mild  folution  of  faccharum  faturni ;  and  the  patient 
fhould  be  kept  upon  a  low,  cooling  regimen. 

I  here  think  it  proper  to  mention  two  remedies  that 
I  have  often  ufed  with  advantage  in  cafes  of  piles. 
The  one  is  an  ointment  compofed  of  equal  parts  of 
oak  galls  finely  powdered,  and  hogs  lard  or  butter : 
this  commonly  gives  more  relief  in  external  hsemor- 
rhoidal  fwellings,  than  any  of  the  fulphur  ointments 
fo  frequently  employed;   and  when  the  feat  of  the 


Chap.  XXXIV.  e>r  Piles,  iy^ 

pain  is  internal,  and  cannot  be  reached  by  an  oint- 
ment, injeftions  of  a  ftrong  intufion  of  galls  may  be 
ufed  inftead  of  it.  The  other  is  a  remedy  that  I  firft 
employed  on  the  fuggefton  of  our  late  jultly  celebrat- 
ed profclfor  Dr.  Cullen ;  balfamum  copaibae.  This 
medicine,  given  to  the  extent  of  fifty,  fixty,  or  eighty 
drops,  morning  and  evening,  not  only  removes  the 
pain  fo  frequently  produced  by  piles,  but  very  com- 
monly anfwers  as  an  eafy  and  certain  laxative. 

Warm  emollient  fomentations  and  poultices  fome- 
times  give  relief  in  piles,  but  as  they  tend,  when  long 
continued,  to  excite  relaxation  in  the  contiguous  parts, 
by  which  very  large  defcents  of  the  gut  are  produced, 
they  (hould  in  every  inftance  be  foon  laid  afide. 

By  the  ufe  of  one  or  other  of  thefe  remedies,  all 
the  ordinary  fymptoms  of  piles  will  in  general  be  re- 
moved :  but  there  are  fome  ftates  of  the  difeafe  that 
can  only  be  relieved  by  a  chirurgical  operation  ;  and 
thefe  particularly  are,  frequent  returns  of  profufe  eva- 
cuations of  blood  from  the  ha^morrhoidal  veffels,  and 
the  piles  becoming  fo  large  as  to  induce  much  pain, 
irritation,  and  even  obftruclion  in  the  under  part  of 
the  reftum. 

When  frequent  returns  of  h^emorrhagy  have  weak- 
ened the  fyftem  too  much  ;  and  when  bloodletting, 
gentle  aperients,  and  a  proper  regimen,  do  not  prove 
effectual,  our  next  refource  is  to  put  a  flop  to  the  dif- 
charge  by  the  direct  application  of  preiTure  to  the 
mouths  of  the  bleeding  veffels.  In  flight  cafes  of  piles, 
this  may  frequently  be  done  by  a  tube  of  filver  wrap- 
ped properly  round  with  foft  linen,  being  pafTed  into 
the  rettum  ;  or  a  piece  of  fheep's  gut,  tied  at  one  ex- 
tremity, being  pufhed  into  the  anus,  and  a  quantity  of 
water  or  any  other  fluid  being  conveyed  into  the  open 
end  of  it,  which  ought  to  be  of  a  length  to  admit  of 
two  or  three  inches  hanging  out  at  the  redum,  almofl 
any  neceffary  prefTure  may  thus  be  applied,  merely  by 

T  2 


27^  Of  Hamorrhoids,        Chap.  XXXIV, 

pufhing  the  water  into  the  upper  part  of  the  gut,  and 
fecuring  it  there  with  a  ligature.* 

In  various  cafes  I  have  proved  fuccefsful  with  this 
remedy,  where  others  have  failed,  and  in  fome  inftan- 
ces  I  have  derived  advantage  from  cold  aftringent  in'- 
fufions  and  folutions  being  thrown  into  the  rc£tum, 
fuch  as  infufions  of  red  rofe  leaves,  walnut-tree  leaves, 
and  oak  bark,  and  folutions  of  alum,  and  even  of  fac- 
charum  faturni,  and  white  vitriol.  When  thefe  rem- 
edies do  not  fucceed,  there  is  often  reafon  to  think, 
either  that  the  veifels  from  whence  the  blood  is  dif- 
charged  lie  too  high  in  the  abdomen  to  admit  of  their 
being  afted  upon  in  this  manner,  or  if  near  the  end 
of  the  gut,  that  they  are  of  a  confiderable  fize  :  in  the 
one  cafe,  we  truft  entirely  to  perfeverance  in  the  means 
that  have  already  been  mentioned  ;  particularly  to  the 
effecl  of  a  low  regimen,  gentle  aperients,  and  the  in- 
ternal ufe  of  alum,  kino,  and  other  aftringents  ;  while 
in  the  other,  if  the  bleeding  veffel  can  pofiibly  be  per- 
ceived, it  ought  at  once  to  be  fecured  with  a  ligature. 
To  thofe  who'  are  not  accuftomed  to  the  application  of 
this  remedy,  it  may  appear  to  be  of  a  hazardous  na- 
ture, but  when  properly  applied,  I  can,  from  much 
experience  of  the  effects  of  it,  venture  to  fay,  that  it 
never  does  harm,  while  it  feldom  fails  to  acl  with  cer- 
tainty in  the  cure.  The  ligatures  may  be  applied  ei- 
ther with  the  crooked  needle  or  tenaculum ;  but  the 
latter  fhould  perhaps  in  every  inftance  be  preferred,  as 
with  it  the  ruptured  veffels  alone  can  be  tied  without 
including  any  of  the  contiguous  parts,  which  cannot 
be  done  when  we  employ  the  crooked  needle. 

I  have  already  obferved,  that  in  fome  in  (lances,  the 
tumors  produced  by  piles  become  very  large.  As 
long,  however,  as  they  are  not  painful,  or  very  incon- 


*  Mr.  Eromfield,  when  treating  of  the  extratSlion  of  the  flone  in  women, 
advifes  the  urethra  to  be  dilated  by  means  of  w;;ler  contaiiuxl  in  the  gut 
of  a  fowl.  In  jnfticc  to  Mr.  Uronifield,  I  mufl:  obferve,  that  the  pra(5lice 
here  recommended  is  taken  from  this  hint. 


Chap.  XXXIV.  or  Piles.  277 

venient,  they  ought  not  to  be  touched  ;  but  whenever 
they  become  fo  large  as  to  obftrud  the  paffage  of  the 
fseces,  they  ought  if  poflible  to  be  removed  :  when 
fituated  near  to  the  verge  of  the  anus,  this  may  com- 
monly be  eafily  done  ;  and  even  when  an  inch  or  more 
up  the  reclum,  they  may  frequently  be  brought  com- 
pletely in  view  by  prefTure,  fimilar  to  what  is  employ- 
ed on  going  to  ftool. 

Various  methods  have  been  in  ufe  for  removing 
thefe  tumors,  namely,  ligatures,  excifion^  and  even 
the  potential  and  aftual  cauteries.  Neither  of  the  lat- 
ter, however,  fliould  be  ever  employed  ;  fo  that  the 
methods  by  ligature  and  excifion  arc  thofe  that  we 
have  to  confider. 

When  a  hemorrhoidal  tumor  is  attached  by  a  fmall 
root,  and  when  therefore  a  ligature  is  eafily  applied, 
we  are  commonly  advifed  to  take  it  off  in  this  man- 
ner;  and  on  the  contrary,  when  it  adheres  to  the  gut 
by  an  extenfive  furface,  we  are  defired  to  diffed  it  oft' 
with  a  fcalpcl.  The  very  reverfe,  however,  fliould  be 
adopted ;  for  when  the  tumors  are  fmall,  and  attach- 
ed by  narrow  necks,  and  when  there  is  therefore  no 
reafon  to  be  afraid  of  any  hemorrhagy  that  may  enfue 
from  removing  them  by  excifion,  as  the  fcalpel  may 
in  this  cafe  be  ufed  with  fafety,  it  ought  undoubtedly 
to  be  preferred,  as  the  eafiefl  and  fpeedieft:  method  of 
finifliing  the  operation  ;  but  v/henever  they  are. large, 
and  when  there  is  reafon  therefore  to  fufpecl  that  the 
arteries  that  fupply  them  with  blood  are  large,  the  lig- 
ature ought  certainly  to  be  employed,  as  the  only  fafe 
means  of  removing  them.  No  good  reafon  has  ever 
been  given  for  confining  the  ufe  of  the  ligature  to  tu- 
mors with  fmall  necks  ;  for  although  in  thefe  it  is 
more  eafily  applied,  yet  with  due  care  and  attention, 
even  fuch  as  have  broad  extenfive  attachments  may 
be  removed  in  this  manner. 

A  needle  armed  with  two  firm  waxed  ligatures  be- 
ing introduced  through  the  middle  of  the  tumor  at 


278      ■    Of  Hamorrhoids,  or  Piles.     Chap.  XXXIV. 

its  bafe,  and  the  ends  of  one  of  them  being  firmly  tied 
round  one  half  of  the  tumor,  vvhilft  the  other  half  of 
it  is  fecured  by  the  other  ligature,  the  whole  may  in 
this  manner  be  removed  with  as  much  certainty  as 
when  the  bafe  is  narrow.  If  the  ligatures  have  been 
properly  applied,  the  tumor  will  commonly  fall  off  in 
the  fpace  of  three  days  :  in  fome  inflances,  they  drop 
off  in  forty-eight  hours,  or  even  in  lefs  5  but  in  gen- 
eral three  days  are  required.  When  the  fcalpel  is  em- 
ployed for  the  removal  of  thefe  tumors,  the  parts 
ihould  be  afterwards  dreffed  with  foft  lint,  covered 
with  any  emollient  ointment ;  but  when  taken  off  with 
ligatures,  no  dreffing  is  neceffary. 

In  the  ufe  of  ligatures  for  this  purpofe,  when  more 
than  one  is  contained  in  the  fame  needle,  their  being 
of  different  colours  tends  to  prevent  confufiou. 


Chap.  XXXV.     CondylomatQus  Eurcfccnces*  279 

CHAPTER     XXXV. 


OF  CONDYLOMATOUS  EXCRESCENCES,  AND  SIMILAR. 
AFFECTIONS  ABOUT  THE  ANUS. 


THE  parts  about  the  anus  are  liable  to  excrefcen- 
ces,  termed  condylomata,  fici,  and  criiliE.  The 
^iftinttions,  however,  which  thefe  names  import,  are 
of  no  moment ;  for  thefe  tumors  are  all  of  the  fame 
nature,  and  are  cured  by  the  fame  means. 

We  fometimes  meet  with  them  in  the  cavity  of  the 
gut  itfelf ;  but  moll  frequently  they  are  confined  to 
the  parts  exterior  to  the  fphinder.  They  are  of  dif- 
ferent degrees  of  hardnefs,  being  in  fome  in  (lances  not 
much  firmer  than  the  parts  with  which  they  are  con- 
ne«^ed,  and  in  others  they  refemble  the  firmeft  fchir- 
rus.  Their  colour  is  allb  very  various  :  in  fome  they 
"are  of  a  pale  white,  and  in  others  of  different  fhades 
of  red.  In  fome  inftances,  a  fingle  excrefcence  or  two 
is  only  met  with  ;  but  in  others  they  cover  almofl  the 
whole  parts  contiguous  tjb  the  anus.  In  fome,  they 
never  become  larger  than  ordinary  warts  ;  and  the 
difeafe,  even  in  its  mofl  advanced  llage,  is  found  to 
confifl;  of  a  number  of  thefe,  either  adhering  together, 
or  lying  in  clofe  contadt.  But  in  others,  the  tumors 
are  from  the  beginning  broad  and  flat,  being  frequent- 
ly of  the  Ihape  and  magnitude  of  fplit  garden  beans. 

Thefe  excrefcences,  on  their  firfl  formation,  feem 
all  to  be  productions  of  the  cuticle ,;  but  when  of  long 
duration,  they  commonly  adhere  to  the  fkin  itfelf,  and 
in  fome  inftances  even  proceed  to  the  depth  of  the 
contiguous  mufcles. 

As  long  as  they  create  no  uneafmefs,  they  fliould 
never  be  touched  ;  and  it  frequently  happens  that  they 
never  become  fo  large  as  to  require  much  attention  ^ 


sSo  Condjlomatous  Excnfcences.     Chap.  XXXV",- 

while  In  fome  they  excite  fo  much  diftrefs,  that  we  are 
obliged  to  remove  them  immediately. 

In  fuch  as  are  foft,  rubbing  them  from  time  to  time 
with  crude  fal  ammoniac,  or  walhing  them  with  a 
ftrong  folution  of  that  fait,  or  with  fpirit  of  hartfliorn, 
will  frequently  remove  them.  The  pulvis  fabinse,  too, 
in  fine  powder,  often  anfwers  the  purpofe,  as  well  as 
red  precipitate  of  mercur}',  particularly  when  mixed 
with  equal  parts  or  thereby  of  calcined  alum  ;  but  all 
of  thefe  remedies  are  flow  in  their  operation  ;  and  when 
the  tumors  are  hard  and  v/arty,  they  have  little  or  no 
efFe*^:.  •  When  they  do  not,  therefore,  fucceed,  v/e  em- 
ploy either  the  fcalpel  or  lunar  cauftic  :  but  when  the 
patient  will  fubmit  to  the  fcalpel,  it  ought  always  to 
be  preferred  ;  for  no  danger  can  arife  from  it,  as  the 
parts  to  be  removed  are  not  fupplied  with  large  blood 
Veflels.  All  the  difeafed  parts  Ihould  be  completely 
removed  ;  and  dry  lint  being  applied  to  the  fores,  they 
fall  afterwards  to  be  drelfed  like  wounds  produced  in 
any  other  way. 

When  the  fears  of  a  patient,  however,  prevent  him 
from  fubmitting  to  this  operation,  cauftic  muft  necefr 
farily  be  employed  :  but  in  the  ufe  of  this  remedy, 
much  attention  is  neceffary,  to  prevent  it  from  fpread- 
ing  to  the  gut ;  for  mifchief  might  enfue  were  it  to  be 
diredly  applied  to  it. 


Chap.  XXXVI.       Of  a  Prolapfus  Am,  28 1 

CHAPTER   XXXVI. 

OF     A     PROLAPSUS     ANI. 

A  PROTRUSION  of  any  part  of  the  reaum  be- 
yond its  ufual  Umits,  Is  termed  a  proh\pfus  ani. 
In  fome  inflances,  the  difplaced  portion  of  gut  is  in- 
confiderable,  but  in  others  it  falls  down  to  a  great 
length. 

The  fphlnder  ani  and  neighbouring  parts,  whilft  lit 
full  (trength,  fervc  as  a  bafe  or  fupport  to  the  fuperior 
part  of  the  gut :  A^hatevcr,  therefore,  tends  to  induce 
any  morbid  debility  of  thefe,  will  neceffarily  have  fome 
influence  in  the  formation  of  a  prolapfus  ani. 

The  mofl  common  caufe,  however,  of  this  protru- 
fion  of  the  gut  is,  frequent  and  violent  exertions  ex- 
cited in  the  reclum  itfelf  by  fome  irritating  caufe  about 
its  extremity ;  thus  producing  what  we  commonly 
term  tenefmus  :  a  frequent  ufe  of  aloctics  is  faid  to  be 
very  apt  to  excite  irritation  in  the  reQum,  although, 
from  much  obfervation,  I  am  now  inclined  to  doubt 
of  the  truth  of  it ;  but  I  have  much  reafon  to  think, 
that  the  fmall  worms  termed  afcarides,  by  lodging 
chiefly  in  the  under  part  of  the  redlum,  and  by  thus 
producing  irritation,  have,  in  different  inflances,  in- 
duced deicents  of  the  gut.  Habitual  coflivenefs,  hcS* 
morrhoidal  fwellings,  and  in  fliort  every  caufe  that: 
ftimulates  the  reftum  to  over  exertion,  will  alfo  be  apt 
to  produce  it. 

The  reclum  often  remains  unreduced  for  a  great 
length  of  time,  and  no  bad  ccnfequences  enfue  :  hence 
it  is  evident,  that  this  portion  of  gut  will  bear  more 
expofure  to  the  air  than  the  other  parts  of  the  intef- 
tincs ;  but  we  ouG^ht  not  from  this  to  be  ever  induced 
to  allow  any  part  of  it  to  remain  long  down,  without 
attempting  to  reduce  it.  By  many,  we  are  defired, 
before  reducing  the  gut,  to  foment  it  well  with  emol- 
lient and  antifeptic  decoclions  j  and  the  operator  is 


282  Of  a  Prolapfus  Ani,       Chap.  XXXVI, 

direfted  to  cover  his  fingers  with  oiled  or  waxed  linen 
before  any  prefTure  is  applied  to  it.  Thefe  previous 
fteps,  however,  are  not  neceflary.  We  fhould  inftant- 
ly  indeed  endeavour  to  return  the  prolapfed  parts, 
without  allowing  them  to  be  expofed  to  fuch  injuries 
as  might  enfue  from  the  delay  in  fomenting  them  ; 
and  as  we  can  handle  the  parts  with  more  exadnefs 
when  the  fingers  are  bare,  than  when  covered  with 
oiled  or  waxed  gloves,  thefe  ought  never  to  be  em- 
ployed ;  but  when  any  covering  is  judged  to  be  ne- 
celfaiy,  a  piece  of  foft  oiled  cotton  cloth  anfwers  the 
purpoie  better  than  any  other. 

The  patient  being  put  into  bed,  and  laid  upon  one 
fide,  or  upon  his  face,  which  anfwers  better,  with  his 
buttocks  elevated  above  the  reft  of  his  body,  the  fur- 
geon  fhould  now  prefs  firmly,  though  equally,  with 
the  palm  of  his  hand  upon  the  under  part  of  the  pro- 
truded gut.  By  a  continuance  of  this  kind  of  pref- 
fure,  the  gut  is  in  general  eafily  reduced  ;  but  when 
this  does  not  fucceed,  we  feldom  fail  by  pufhing  up 
the  fuperior  part  of  the  gut  with  the  fingers,  while  the 
palm  of  the  other  is  made  to  fupport  the  inferior  part 
of  it.  When,  indeed,  the  prolapfed  portion  of  gut 
has  previoully  become  much  inflamed  and  fwelled,  no 
means  of  redudion  will  fucceed  till  thefe  are  remov- 
ed. In  this  fituation,  therefore,  before  preflure  is  em- 
ployed, it  may  be  proper  to  difcharge  a  quantity  of 
blood  in  proportion  to  the  ftrength  of  the  patient,  par- 
ticularly with  leeches,  from  the  neighbourhood  of  the 
anus  ;  the  gut  fhould  be  fomented  with  a  weak  folu- 
tiort  of  faccharum  faturni,  moderately  warm ;  and 
when,  by  thefe  means,  the  fwelling  is  nearly,  or  per- 
haps entirely  removed,  the  prolapfed  parts  will  be  ea- 
fily reduced  in  the  manner  I  have  already  advifed. 

We  feldom,  indeed,  find  it  difficult  to  reduce  pro- 
trufions  of  the  redum  ;  but  it  is  often  no  eafy  matter 
to  retain  them  after  they  are  replaced  :  for  the  fphinc- 
ter  ani,  by  repeated  defccnts  of  the  gut,  often  becomes 
fo  relaxed  that  it  does  not  retain  it  j  fo  that  a  protru- 


Chap.  XXXVI.       Of  a  Prolapfus  Anl  283 

fion  takes  place,  not  only  on  going  to  ftool,  but  often 
on  every  attempt  to  walk,  or  to  fit  in  an  erect  poflure- 

When  the  gut  thus  falls  readily  down,  much  bene- 
fit may  be  derived,  from  a  proper  bandage.  On  the 
protruded  portion  of  gut  being  replaced,  if  a  thick 
comprefs  of  linen  is  apphed  directly  upon  the  anus,  a 
proper  application  of  the  T  bandage  over  the  whole 
proves  often  ufeful.  But  in  Plate  LXXVII.  fig.  3.  I 
have  delineated  a  trufs  originally  invented  for  this 
purpofe  by  the  late  Mr.  Gooch,*  by  which  the  parts 
may  be  more  completely  retained  than  with  any  other 
bandage,  while  at  the  fame  time  the  patient  may  be 
allowed  more  freedom  than  he  could  otherwife  poffi- 
bly  venture  on. 

The  parts  that  protrude  upon  going  to  flool  being 
immediately  replaced,  an  operation  that  the  patient 
himfelf  can  often  accomplifh,  this  trufs  fliould  be  di- 
rectly applied  ;  and  with  a  view  to  ftrengthen  the 
fphindter  ani  and  neighbouring  parts,  the  debility  of 
which  is  often  to  be  confidered  as  thefole  caufe  of  the 
defcent,  the  patient  fhould  be  advifed  to  the  ufe  of 
fteel,  bark,  cold  bathing,  and  dafhing  cold  water  up- 
on the  buttocks  and  under  part  of  the  back  :  confid- 
erable  advantage  has  alfo  been  experienced,  from  a 
frequent  ufe  of  aflringent  injedions,  particularly  infu- 
fions  of  galls  and  oak  bark  ;  and  when  a  fmall  pro- 
portion of  opium  is  added  to  the  liquor,  the  irritabili- 
ty in  the  redtum,  which  is  often  to  be  confidered  as 
the  original  caufe  of  the  difeafe,  is  thereby  more  effec- 
tually removed  than  in  any  other  way.  I  have  fome- 
times  ventured  to  add  a  fmall  quantity  of  aliim,  and 
faccharum  faturni,  to  thefe  injections  ;  but  in  general, 
any  addition  of  a  faline  nature  is  here  inadmiflible, 
from  the  irritation  that  fuch  remedies  commonly  give 
to  the  gut. 

By  one  or  other  of  thefe  means,  the  difeafe  may  ei- 
ther be  entirely  cured,  or  at  leaft  fo  far  palliated  as  to 
obviate  every  inconvenieijce  from  its  continuance. 

*  vide  Cafes  and  Pra<SUcal  Remarks  ia  Surgery,  &c.  vol.  IL  by  B.  Gooch. 


384.         Of  an  Imperforated  Anus,     Chap.  XXXMI. 


CHAPTER     XXXVII. 


OF  AN  IMPERFORATED  ANUS. 


AN  imperforated  anus  is  not  an  uncommon  oc- 
currence, fo  that  every  midwife  fhould  examine 
with  attention  the  ftate  of  this  and  other  natural  paf- 
fages  immediately  after  birth. 

In  fome,  the  end  of  the  reclum  is  fomewhat  prom- 
inent where  the  anus  ought  to  be,  being  only  covered 
with  fkin  and  a  fmall  quantity  of  cellular  membrane  : 
hut  in  others,  no  veftige  of  the  redum  is  perceived  ; 
and  the  fkin  retains  its  natural  appearance,  without 
being  any  where  elevated  betvreen  the  fcrotum  and 
point  of  the  coccyx. 

In  fome,  the  redum  terminates  within  an  inch  of 
the  ordinary  feat  of  the  anus  ;  in  others,  it  has  reach- 
ed no  farther  than  the  top  of  the  facrum.  In  fome  it 
has  been  known  to  terminate  in  the  bladder  j  and  in 
(Others,  in  the  vagina. 

When  the  affiflance  of  a  furgeon  is  required,  as 
death  mud  enfue  if  a  proper  vent  be  not  obtained  for 
the  fiEces,  no  time  fhould  be  lofl  in  deliberation.  If 
the  end  of  the  gut  is  found  to  be  covered  with  fkin 
only,  and  if  a  protuberance  is  formed  by  the  faeces 
pu.lhiiig  it  forward,  all  that  the  furgeon  can  do,  is  with 
a  i'calpel  or  lancet  to  make  an  opening  of  a  fufficient 
fize  ;  but  when  this  kind  of  direction  is  not  met  with, 
more  difficulty  and  danger  is  to  be  dreaded. 

When  the  gut  is  deep,  an  incifion  of  an  inch  in 
length  fhould  be  made  diredly  on  the  fpot  where  the 
anus  ought  to  be  ;  and  this  fhould  be  continued  with 
gradual  and  repeated  ftrokes  of  the  fcalpel,  in  the  di- 
re£lion  that  the  redum  ought  to  take  ;  not  in  a  direct 
courfe  through  the  axis  of  the  pelvis  j  for  in  that  di- 


Chap.  XXXVII.     Of  an  Imperforated  A ?nis,  285 

reclion  the  vagina  or  bladder,  or  perhaps  both,  might 
be  injured ;  but  backwards  along  the  coccyx,  where 
the  rifk  oi  \younding  any  part  of  importance  is  Icfs. 
The  bed  director  is  the  finger  of  the  operator.  The 
forefintrer  of  one  hand  being  inferted  into  the  wound, 
and  palled  towards  the  coccyx,  the  furgeon,  with  the 
fcalpel  in  the  other,  ihould  diflcct  gradually  in  this  di- 
redion,  either  till  he  meets  with  faeces,  or  till  the  fcal- 
pel has  reached  at  leafl  the  full  length  of  his  finger ; 
and  if,  after  all,  the  faeces  are  not  reached,  as  death 
mufi:  enfue  if  more  be  not  attempted,  I  would  advife 
a  long  trocar  to  be  pulhed  forward  upon  the  finger, 
in  fuch  a  diredlon  as  the  operator  thinks  will  moil 
probably  meet  with  the  gut. 

In  this  manner  many  lives  have  been  faved  which 
would  othcrwife  have  been  loft.  I  myfclf  have  had 
two  fuch  cafes  ;  in  both  of  which  the  gut  lay  deep, 
and  in  both  I  was  fortunate  enough  to  form  an  anus, 
which  for  many  years  has  continued  to  anfwer  the 
purpofe  fufficiently.  But  in  both  it  was  exceedingly 
difficult  to  preferve  the  palTage  fufficiently  wide  :  for 
as  foon  as  the  doffi's  of  Hnt  and  other  tents  employed 
for  preferving  the  paiTage  w^re  withdrawn,  a  very 
ftrong  contraction  took  place,  by  which  the  opening 
was  occafionally  nearly  obliterated.  Sponge  tent, 
gentian  root,  and  other  fubftances  that  fwell  by  moif- 
ture,  were  at  different  times  employed  ;  but  thefe  uni- 
formly gave  fo  much  pain  and  irritation,  that  they 
could  not  be  continued.  They  are  commonly,  indeed, 
recommended  in  fuch  cafes  ;  but  all  who  have  ever 
employed  them  in  parts  fo  exquifitely  fenfible  as  the 
return,  will  foon  be  convinced  of  the  impropriety  of 
the  advice. 

Doffils  of  foft  lint  moiftened  In  oil,  and  rolls  of  bou- 
gie plafter  of  a  proper  fize,  were  found  to  Irritate  Icfs, 
and  to  anfwer  better  than  any  other  application ;  and 
for  the  purpofe  of  dilating  the  pailage,  when,  at  dif- 
ferent tiuies  during  the  cure,  it  was  found  to  have  be- 


286  Of  an  Imperforated  Anus.     Chap.  XXXVtl^ 

come  too  ftrait,  the  method  I  have  already  advifed 
(when  fpeaking  of  piles)  of  comprelTmg  blood  vefl'els 
in  the  reclum  by  introducing  a  Iheep's  gut,  fliut  at 
one  end,  into  it,  and  forcing  water  up  by  the  other, 
was  employed  with  advantage.  But  upon  the  whole, 
although  this  part  of  the  cure  may  appear  to  thofe 
who  have  not  met  with  fuch  cafes,  to  be  fimple  and 
eafy,  it  is  found  to  be  much  otherwife  in  pra6lice. 
Indeed,  no  cafe  in  which  I  was  ever  concerned,  gave 
fo  much  perplexity  and  trouble,  either  to  the  patient 
or  myfelf,  as  each  of  thofe  I  have  mentioned  ;  for  al- 
though in  both,  the  openings  were  at  firft  made  fufii- 
ciently  large,  yet  nothing  but  continued  attention  for 
the  fpace  of  eight  or  ten  months,  prevented  the  necef- 
fity  of  a  frequent  repetition  of  the  operation.  When 
the  fkin  alone  is  to  be  cut,  it  is  a  fimple  matter  indeed  ; 
for  in  this  cafe  nothing  is  in  general  neceffary  but  the 
introduction  of  a  doffil  of  foft  lint  for  a  few  days  into 
the  opening.  But  when  the  redum  lies  deep,  I  am 
inclined  to  think,  from  the  event  of  thofe  cafes,  that 
although  ultimately,  a  complete  cure  may  commonly 
be  obtained  after  a  free  difcharge  of  fseces  is  procured, 
that  much  care  and  attention  on  the  part  of  the  oper- 
ator will  always  be  required  for  a  confiderable  time 
after  the  operation  ;  and  in  general  we  may  fuppofe, 
that  the  difficulty  will  be  in  proportion  to  the  depth 
of  the  cut. 

Even  where  the  gut  terminates  in  the  bladder  or 
vagina,  the  operation  fhould  be  advifed  :  for,  as  in  the 
one  cafe,  all  the  fseces  mufl  be  emptied  into  the  blad- 
der, there  would  be  much  rifk  of  fuch  accumulations 
being  formed  in  it  as  would  foon  put  a  total  flop  to 
the  difcharge  by  the  urethra  ;  and  in  the  latter,  where 
the  rectum  terminates  in  the  vagina,  much  diflrefs 
would  enfue  from  it,  which  a  fuccefsful  ifTue  of  this 
operation  alone  could  prevent. 

When  it  unfortunately  happens  that  no  paffage  is 
obtained  for  the  farces  by  any  of  the  means  that  I  have 


Chap.  XXXVII.     Of  an  Imperforated  Anus,  287 

mentioned,  might  not  we  attempt  an  opening  above 
the  pubes,  with  the  view  of  reaching  the  under  extrem- 
ity of  the  colon,  or  perhaps  on  the  right  fide,  fo  as  to 
reach  the  caput  coli,  for  the  purpofe  of  making  an  ar- 
tificial anus  ?  It  is  true,  that  the  chance  of  fuccels  from 
fuch  a  meafure  would  not  be  great ;  and,  even  admit- 
ting that  the  attempt  fhould  fucceed  in  the  mofl  com- 
plete manner,  the  difcharge  of  faeces  from  the  open- 
ing would  always  prove  troublefome  and  very  uncom- 
fortable ;  but  the  melancholly  idea  of  leaving  a  child 
in  fuch  a  Hate,  to  die  in  much  pain,  muft  prove  fo 
highly  diftrefsful,  both  to  the  parents  and  operator,  as 
•would  incline  me  rather  to  advife  even  the  doubtful 
and  defperate  remedy  I  have  mentioned. 


288  OftheFiJlulu  Chap.  XXXVIIL 


CHAPTER  XXXVIII. 


OF    THE    FISTULA    IN    ANO. 


E 


VERY  finuoas  ulcer  in  the  neighbourhood  of* 
the  re6tuni  is  termed  a  fiflula  in  ano.  This  is 
the  mofl  accurate  and  niofl  fiinple  idea  that  can  be 
given  of  the  difeafe  :  for  although,  in  different  inftan- 
ces  it  aifumes  a  variety  of  appearances,  and  akhough 
the  defcriptions  given  of  thefe  have  tended  to  render 
this  part  of  chirurgical  pathology  extremely  perplex- 
ed, yet  whoever  uill  attentively  confider  all  the  civ- 
cumftances  tl;^^t  relate  to  it,  will  lind,  that  the  fiftula 
in  ano  is  of  a  nature  as  determined  and  fixed  as  any 
difeafe  that  falls  within  the  province  of  furgery. 

Several  varieties  of  this  ulcer  are  defcribed  by  au- 
thors :  an  external  opening  contiguous  to  the  anus, 
communicating  with  an  internal  ulcer,  but  without 
any  connection  with  the  re£lum,  is  termed  an  incom- 
plete uflula  :  when  the  ulcer  has  tv/o  outlets,  one  ex- 
ternal, and  the  other  opening  into  the  gut,  the  fiftula 
is  faid  to  be  complete  ;  and  again,  when  it  communi- 
cates with  the  gut  only,  without  any  external  open- 
ing, it  is  termed  an  internal  or  occult  fiftula. 

This  difeafe  has  been  likewife  diftinguifiied  into  fim- 
ple  and  compound.  When  the  parts  through  which 
the  fmus  runs  are  hard  and  tumefied,  or  when  a  com- 
munication is  difcovered  between  the  ulcer  and  the 
bladder,  vagina,  os  facrum,  and  other  contiguous  parts, 
the  fiftula  is  faid  to  be  of  a  complicated  or  compound 
nature  ;  and  it  is  termed  a  fimple  fiftula,  when  all  the 
neighbouring  parts  are  found. 

In  the  commencement  of  the  difeafe,  the  contigu- 
ous parts  are  very  commonly  found  ;  but  whenever 
the  ulcer  has  been  of  long  duration,- not  only  the  parts 


Chap.  XXXVIIL  in  Ano.  289 

about  the  anus,  but  even  the  perinccum  and  buttocks, 
frequently  become  difeafed.  This  may  depend  on  dif- 
ferent caufes,  but  it  appears  rnofl  frequently  to  pro- 
ceed from  the  matter  of  the  abfcefs  or  fmus  not  find- 
ing a  proper  vent,  and  from  its  being  allowed  there- 
fore to  fpread  along  the  contiguous  cellular  fubftance* 

Thus,  we  fometimes  find,  that  the  perinsL'um  and 
part  of  the  buttocks  have  become  hard,  with  various 
finufes  running  in  different  parts  of  them  ;  and  when 
the  matter  is  (harp  and  acrid,  inftanccs  occur  of  the 
OS  facrum  becoming  carious,  and  of  the  bladder  and 
vagina  being  corroded  fo  as  to  have  the  contents  of 
the  redum  emptied  into  them.  This  laft  ftage  of  the 
difeafe  is  not,  however,  often  met  with  j  and  it  would 
probably  never  occur,  if  the  difeafe  were  properly 
managed  from  the  beginning,  by  a  free  difcharge  be- 
ing given  to  the  matter. 

In  enumerating  the  caufes  of  this  difeafe,  it  may  be 
remarked,  that  v/hatever  tends  to  produce  matter 
abdut  the  anus,  may  be  confidered  in  this  light.  Thus 
the  piles,  condylomatus  tumors  in  the  neighbourhood 
of  the  reclum,  !->ardened  fseces  collefted  in  the  extre- 
mity of  the  gut,  and,  in  Ihort,  whatever  can  excite  ir- 
ritation and  inflammation  of  thefe  parts,  will  occafion- 
ally  terminate  in  fuppuration  ;  and,  if  the  matter  thus 
produced  be  not  ablorbed,  or  if  the  fore  arifing  from 
the  burRing  of  the  abfcefs,  does  not  foon  heal,  a  fmu- 
ous  ulcer  will  very  readily  form.  I  may  alfo  remark, 
that  abfceffes  in  thefe  parts  frequently  fucceed  to  fevers 
and  other  difeafes  of  the  conititution. 

The  circulation  being  more  languid  here  than  in 
other  parts,  every  inflammatory  tumor  that  forms  in 
it  is  not  only  more  apt  to  fuppurate,  but  the  fores  that 
enfue  heal  with  difficulty.  They  always  excite  much 
diflrefs,  and  require  much  caution  and  attention,  in 
the  treatment.  We  have  it  commonly  in  our  power, 
however,  with  proper  management  from  the  fuft  ap- 
pearance of  inflammation  about  the  anus,  to  preveuE 

Vol.  III.  U 


29C  Of  the  Tijlula        Chap.  XXX  Vni. 

much  of  that  pain  and  mifery,  that  thefe  tumors,  when 
neglected,  are  ultimately  fure  to  induce. 

As  foon  as  this  kind  of  tumor  has  advanced  fo  far 
as  to  make  it  probable  that  fuppuration  will  enfue, 
every  means  that  can  accelerate  the  formation  of  mat- 
ter fhould  be  advifed  :  and  as  nothing  anfwers  this 
purpofe  with  more  certainty  than  a  continued  applica- 
tion of  heat,  warm  emollient  poultices,  fomentations, 
and  the  fleams  of  warm  water,  are  chiefly  to  be  truft- 
ed.  By  a  due  application  of  thefe  remedies,  the  tu- 
mor may  in  general  be  made  to  fuppurate  quickly ; 
and  as  foon  as  matter  is  formed,  it  ought  to  be  dif- 
charged  by  a  free  incifion  in  the  moil  depending  part 
of  it* 

In  this  ftage  of  the  difeafe,  much  more  depends  up- 
on the  abfcefs  being  freely  and  timoufly  laid  open, 
than  is  commonly  imagined  ;  for  if  this  is  long  delay- 
ed, or  if  the  opening  is  not  made  of  a  fize  fufficient 
for  difcharging  all  the  matter,  it  is  thus  allowed  to 
pafs  into  the  contiguous  cellular  fubllance,  fo  as  to 
feparate,  not  only  the  fl-iin  but  all  the  under  part  of 
the  rectum,  from  the  mufcles  and  other  parts  with 
which  they  naturally  lie  in  contact :  and  in  this  man- 
ner, inflead  of  a  fmiple  fore,  which,  when  the  abfcefs 
is  rightly  treated,  is  all  that  we  ought  to  meet  with, 
the  whole  under  part  of  the  gut  is  in  fome  inilances 
entirely  feparated  from  the  furrounding  parts,  and  a 
variety  of  fmufes  form  in  different  direftions,  either 
along  the  perineum,  or  by  the  fide  of  the  gut,  and  in 
fome  inflances  among  the  mufcles  of  the  hips. 

With  a  view,  therefore,  to  prevent  thefe  diflrefsful 
confequences,  as  foon  as  an  abfcefs  in  this  fituation 
is  found  to  contain  matter,  it  ought,  as  I  have  obferv- 
ed  already,  to  be  opened  by  a  free  incifion  ;  by  which 
means,  and  with  due  attention  to  the  fubfequent  treat- 
ment of  the  fore,  if  the  conflitution  is  otherwife  found, 
a  fpeedy  cure  may  in  general  be  expelled. 

The  matter  being  difcharged,  doflils  of  lint  are 
commonly  crammed  into  the  fore,  with  a  view  to  pre- 


Chap.  XXXVIII.  in  Am.  291 

vent,  as  it  is  faid,  the  parts  which  have  been  newly- 
divided  from  adhering  too  foon.  This,  however,  is  a 
very  erroneous  pradice  :  for  extraneous  fubflances  of 
every  kind,  by  the  irritation  that  they  give  to  the  rec- 
tum, ahnoft  always  do  mifchief ;  and,  if  the  opening 
is  of  a  fufficient  fize,  there  is  no  necelTity  for  this  pre- 
caution, as  the  conftant  difcharge  of  matter  from  the 
fore,  proves  in  general  fufficient  for  preferving  it  of  a 
fize  adequate  to  the  quantity  produced  ;  and  this  I 
may  remark  is  the  principal  objeft  we  have  in  view 
from  the  operation. 

Inflead  of  irritating  the  parts,  therefore,  by  the  in- 
troduction of  dollils,  as  foon  as  the  matter  of  the  ab- 
fcefs  has  been  freely  difcharged,  the  fore  (hould  be 
merely  covered  with  foft  lint  fpread  with  any  mild 
ointment,  and  an  emollient  poultice  applied  over  the 
whole. 

Any  hardnefs  that  did  not  difappear  during  the  fup- 
puration,  will  thus  be  foon  removed,  and  a  cure  will 
in  general  be  quickly  obtained. 

It  mod  frequently,  however,  happens,  that  the  aid 
of  furgery  is  not  defired  in  this  firft  and  very  fimple 
ftate  of  the  difeafe ;  nor  till  the  abfcefs  has  burft  of 
itfelf,  and  perhaps  at  an  improper  part ;  and  till  of 
courfe  much  mifchief  is  produced,  by  the  matter  hav- 
ing infmuated  into  the  furrounding  cellular  fubftance  : 
in  this  fituation,  one  or  more  finufes  are  commonly 
met  with,  forming,  according  to  their  duration  differ- 
ent degrees  or  ftages  of  the  real  fiflula  in  ano. 

When,  in  this  llate  of  the  difeafe,  the  advice  of  a 
pratlitioner  is  defired,  the  firft  objed  he  fhould  have 
in  view,  is  to  difcover  with  accuracy  the  courfe  of 
the  finufes  ;  for  nothing  can  with  propriety  be  done 
till  this  is  accompHflied.  When  the  finufes  difcharge 
their  contents  by  external  openings,  the  direclion  in 
which  they  run  is  for  the  mod  part  eafily  difcov- 
ered :  if  they  run  along  the  perin^eum,  or  fpread 
among  the  mufcles  of  the  hips,  a  probe,  introduced 
u  2 


292  Of  the  Fijlula        Chap.  XXXVIII. 

in  the  ufunl  manner  will  readily  pafs  along  the  whole 
of  them  :  but  when  any  of  the  finuies  follow  the  di- 
reftion  of  the  gut,  the  forefinger  of  one  hand,  after 
being  well  oiled,  fliould  be  introduced  into  the  rec- 
tum, at  the  fame  time  that  the  probe  is  entered  at  the 
wound  with  the  other :  by  this  means  we  not  only 
prevent  the  gut  from  being  much  injured  by  the  probe, 
but  if  any  communication  has  taken  place  between  the 
gut  and  the  fmus,  it  is  in  this  manner  eafily  difcover- 
ed,  by  the  point  of  the  probe  pafTmg  from  the  fmus, 
and  being  found  in  the  gut  with  the  finger.  In  a  few 
cafes,  however,  even  when  we  know  that  the  fmus 
communicates  with  the  gut,  the  probe  does  not  pafs 
eafily  from  one  to  the  other ;  but  with  due  perfever- 
ance  we  always  fucceed ;  and  if  the  probe  is  rightly 
managed,  it  may  always  be  done  without  riik  of  hurt- 
ing the  gut. 

As  our  knowing  with  certainty,  whether  the  fmus 
communicates  with  the  gut  or  not,  is  of  much  import- 
ance in  the  cure,  nothing  fliould  be  omitted  that  may 
enable  us  to  determine  the  point  with  precifion. 
When  air  or  faeces  are  difcharged  by  the  fmus,  or 
when  water  or  any  other  fluid  inje£ted  into  it  is  re- 
turned by  the  anus,  the  exiflence  of  fuch  a  commu- 
nication cannot  be  queftioned. 

The  abfence,  however,  of  thefe  tefls,  does  not  im- 
ply that  no  communication  takes  place  between  the 
gut  and  the  finus :  for  we  know  that  the  pafTage  of  fae- 
ces from  the  rectum  into  fores  of  this  defcription,  does 
not  always  happen  ;  and  we  may  eafily  fuppofe  it  pof- 
fible  for  an  opening  between  the  finus  and  the  gut, 
to  be  fo  formed  as  to  prevent  the  pafiage  of  liquids 
from  one  to  the  other. 

When,  by  a  repetition  of  cautious  trials  with  the 
probe,  or  with  injections  of  warm  water  into  the  fores, 
the  courfe  of  the  different  finufes  is  difcovered,  the 
method  of  cure  is  next  to  be  determined.  In  a  pre- 
ceding part  of  this  work,  the  method  of  curing  fmu- 


Chap.  XXXVIII.  in  Ano.  293 

fes  has  been  pointed  out:*  but  from  the  nature  and 
fituation  of  the  parts  in  which  this  variety  of  the  dif- 
eafe  is  feated,  fome  peculiarities  occur  in  regard  to  the 
cure. 

Aftringent  injections,  paftes  and  ointments  of  the 
fame  nature,  have  at  different  times  been  recommend- 
ed for  putting  a  flop  to  the  difcharge  of  thefe  fmufes. 
But  the  cauftic  property  of  tliefe  remedies  is  by  no 
means  fuited  to  the  irritability  of  the  parts  in  which 
this  difeafe  is  feated  ;  nor  have  they  by  experience 
been  found  to  anfwer  the  intention  for  which  they 
were  propofed :  they  have  now,  therefore,  very  uni- 
verfally  fallen  into  difcredit. 

I  have  elfewhere  fhown,  that  the  leading  objed  to 
be  kept  in  view  in  the  treatment  of  fmufes,  is  the  de* 
ftruftion  or  annihilation  of  the  cavities  from  whence 
the  matter  is  difcharged.  With  a  view  to  this,  dif- 
ferent means  have  been  advifed.  Where  prelfure  can 
be  employed,  the  fides  of  fmufes  are,  in  fome  inflan- 
ces  made  to  adhere  by  means  of  it ;  but  in  the  fiftula 
in  ano,  this  method  of  cure  is  inadmiffible,  as  in  this 
fituation  no  regular  or  equal  prefl'ure  can  be  applied. 

This  being  the  cafe,  and  knowing  that  adhefion 
readily  takes  place  between  contiguous  parts  in  a  ftate 
of  inflammation,  we  endeavour  to  make  thofe  parts 
inflame  that  we  wifh  to  adhere  to  each  other.  It  is 
perhaps  indeed  a  doubtful  point,  whether  animal  fub- 
ftances  can  be  made  to  adhere  permanently  by  any 
other  means  than  through  the  intervention  of  inflam- 
mation. 

For  the  purpofe  of  exciting  this  inflammatory  or 
adhefive  flatft  of  a  fmus,  fo  neceffary  for  the  reunion 
of  its  fides,  different  means  may  be  employed.  It 
may  be  accomplifhed  either  by  the  introdudion  of  a 
cord  of  cotton  or  filk  along  the  courfe  of  the  fore,  or 
by  laying  the  finus  open  through  its  whole  length,  fo 
as  to  convert  it  as  nearly  as  pofllble  into  the  ftate  of 
a  recent  wound. 

*  Vide  Chapter  V,  Sc«5Vion  V. 


294  OftheFiJiuIa         Chap.  XXXVIII. 

In  other  parts  of  the  body,  I  have  advifed  the  ufe 
of  a  cord,  or  feton  as  it  is  termed,  in  preference  to 
every  other  method  of  cure ;  as  by  means  of  it,  we 
have  it  in  our  power  to  excite  ahnoft  any  degree  of 
inflammation,  without  any  of  the  difadvantages  that 
fometimes  enfue  from  the  extenfive  cicatrix  of  a  large 
wound.  In  the  fiftula  in  ano,  however,  the  feton 
cannot  be  employed  ;  for  the  irritation  that  it  would 
excite,  would  prove  too  fevere  a  flimulus  for  the  rec- 
tum, with  which  it  would  at  all  times  be  in  immedi- 
ate conta6l. 

As  in  this  fituation,  therefore,  aflringent  and  efcha- 
rotic  injections  and  paftes  cannot  be  employed  with 
fafety,  as  preflTure  is  inadmiffible,  and  as  cords  of  even 
the  fofteft  materials  would  excite  a  very  infupportable 
degree  of  irritation  ;  we  are  under  the  neceffity  of 
employing  the  only  other  remedy  by  which  a  due  de- 
gree of  inflammation  can  be  induced,  namely,  a  free 
and  extenfive  incifion  along  the  whole  courfe  of  the 
fmus,  commencing  at  one  end  of  it,  and  terminating 
at  the  other. 

Having  thus  endeavoured  to  afcertain  the  proper 
method  of  cure,  we  fhall  now  proceed  to  defcribe  the 
eafielt  and  mofl  efl'eclual  manner  of  putting  it  in  prac- 
tice. 

The  courfe  of  the  different  fmufes  having  been  dif- 
covered  by  a  previous  fearch  in  the  manner  I  have 
advifed,  as  it  is  of  importance  to  have  the  alimentary 
canal,  and  particularly  the  re£lum,  emptied,  a  purge 
fhould  be  given  on  the  preceding  day,  and  a  glyfter 
an  hour  or  two  before  the  operation. 

The  operation  is  often  done  while  the*[)atient  ftands 
with  his  back  to  a  clear  light ;  but  it  anfwers  better 
to  place  him  upon  a  table,  in  the  fame  manner  as  is 
done  for  the  operation  of  lithotomy,  with  his  legs  bent 
and  kept  afunder  by  an  afliftant  on  each  fide. 

The  patient  being  firmly  fecured  in  this  fituation, 
the  furgeon,  after  dipping  the  forefinger  of  his  left 
hand  in  oil,  fliould  pafs  it  as  far  as  it  will  reach  into  the 


Chap.  XXXVIII.  inAuo,  295 

re£tum  :  with  his  right  hand,  he  muft  now  enter  the 
point  of  the  probe  pointed  biftoury,  at  the  external 
opening  of  the  fore  ;  and  having  pafled  it  along  the 
whole  length  of  the  finus,  till  he  feels  the  point  of  it 
through  the  opening  in  the  gut,  upon  his  finger  in  the 
anus  ;  (for  I  am  here  fuppofing  that  a  communication 
takes  place  between  the  fmus  and  the  rectum  ;)  he  is 
now  to  pufii  the  point  of  it  in  upon  his  finger ;  by 
means  of  which,  he  not  only  proteds  the  oppofite  fide 
of  the  gut,  but  by  thus  direding  the  point  of  the  in- 
ftrument,  he  cuts  fleadily,  and  the  fmus  is  in  this 
manner  laid  open  with  much  eafe  from  one  end  to 
the  other.  This  being  done,  if  any  other  external 
openings  are  perceived,  the  finger  fhould  be  again 
paiTed  into  the  redum,  and  every  fore  that  is  met  with 
ihould  be  laid  open  in  the  fame  manner.  The  biftou- 
ry to  which  I  allude  is  delineated  in  Plate  LXIV.  fig, 
2.  and  4. 

By  many  it  is  fuppofed,  that  every  external  open- 
ing that  occurs  here,  communicates  with  a  feparate 
and  diftincl  fmus  ;  and  fome  have  gone  fo  far  as  to 
fay,  that  thefe  again  are  commonly  found  to  commu- 
nicate by  fepaiate  openings  vidth  the  gut.  This,  how- 
ever, is  feldom  or  never  the  cafe  ;  for  I  have  very 
univerfally  found,  that  all  the  external  fmufes  com- 
municate with  one  common  fore  or  abfcefs,  and  that 
this,  in  a  great  proportion  of  cafes,  perhaps  in  ninety- 
nine  of  every  hundred,  communicates  with  the  rec- 
tum by  one  aperture  only  :  and  at  any  rate,  the  means 
to  be  employed,  are  in  both  cafes  the  fame»  Whe- 
ther the  external  or  internal  openings  communicate 
with  one  or  with  more  abfcefles,  they  fliould  be  laid 
freely  open  from  one  end  to  the  other. 

In  almoft  every  inftance,  however,  we  find,  that 
when  the  principal  fmus  is  laid  open  through  its  whole 
courfe,  from  the  entrance  of  the  knife  to  the  aperture 
in  the  reftum,  the  others  are  found  to  run  no  farther 
than  into  fome  part  of  the  fore,  without  communicat- 


296  OftheFiJlula        Chap.XXXVIIL 

ing  diredly  with  the  gut ;  fo  that  their  entire  divifion 
is  eafily  and  quickly  accomplifhed. 

I  have  dehred,  in  fcarching  for  the  different  finufes, 
that  this  part  of  the  operation  may  be  accurately  done  ; 
fo  that  it  may  be  known  with  certainty,  whether  the 
fores  communicate  with  the  gut  or  not :  if  a  commu- 
nication is  difcovered,  the  knife  fhould  enter  by  this 
opening  from  the  fmus  into  the  gut ;  for  the  opening 
is  commonly  at  the  mod  fiiperior  point  of  the  fmus, 
and  it  is  likewife  proper  that  the  knife  fliould  be  made 
to  pafs  in  fuch  a  direction  that  the  aperture  into  the 
gut  may  form  a  part  of  the  incifion  :  for  if  this  fhould 
not  be  done,  httle  or  no  advantage  might  be  derived 
from  the  operation ;  the  parts  would  not  readily  ad- 
here at  this  point  j  and  the  faeces  getting  accefs  to  the 
cellular  fubftance  behind  the  gut,  would  be  apt  to 
give  rife  to  a  new  collection  of  matter. 

It  frequently  happens,  however,  that  no  direfl:  com- 
munication can  be  difcovered  between  the  finus  and 
reOium  ;  in  which  cafe  the  hflula,  as  I  have  already 
remarked,  is  faid  to  be  Incomplete  :  but  in  the  meth- 
od of  cure,  the  treatment  is  nearly  the  fame  as  when 
fuch  a  communication  takes  place  ;  only  with  this 
difference,  that  in  the  latter,  the  point  of  the  bifloury 
paffes  into  the  gut  at  the  aperture  found  In  it ;  where- 
as, in  the  other,  an  opening  nuift  be  made  in  it  at  the 
fuperior  part  of  the  fnius,  by  pufhing  the  point  of  the 
bifloury  againfl  the  finger  in  the  rectum  ;  and  this 
being  done,  the  operation  is  to  be  finiflied  in  the  man- 
ner I  have  mentioned,  by  drawing  the  point  of  the  in- 
ftrument  out  at  the  anus,  fo  as  to  divide  the  finus 
through  its  whole  length. 

In  the  courfe  of  this  operation,  the  fphin£ter  ani  is 
always  divided  if  the  fiflula  penetrates  to  any  confid- 
erable  height  in  the  rectum  :  but  this  is  not  of  fuch 
importance  as  at  firfl  fight  might  be  imagined  ;  for 
although  fome  degi'ee  of  inability  to  retain  the  fasces 
frequently  enfues  for  a  (hort  while  after  the  operation, 
yet  experience  fhows  that  the  parts  in  general  recover 


Chap.  XXX\niI.  in  Ano.  ic^y 

their  tone  very  completely,  infomuch  that  Tx-ant  of  re- 
tention is  fcarcely  ever  at  laft  mentioned  by  the  pa- 
tient, as  any  of  the  inconveniencies  that  enfue  from  it. 

Various  inftruments  have  been  propofed  for  eftecl- 
ing  this  operation  ;  but  none  of  them  anfwer  the  pur- 
pofe  with  fo  much  eafe  and  fafety  as  the  probe  point- 
ed biftoury.  A  razor,  with  a  probe  point,  Plate  XCI. 
fig.  I.  may  be  ufed  in  nearly  the  fame  manner;  but 
the  biftoury  is  pofTefled  of  all  the  advantages  attend- 
ing the  razor,  and  as  it  can  be  directed  with  more 
fteaJinefs,  it  ought  to  be  preferred. 

Some  have  objected  to  this  mode  of  operating,  that 
in  the  cafe  of  an  incomplete  fiftula,  the  point  of  the 
biftoury,  on  being  pufhed  through  the  gut  will  be  apt 
to  hurt  the  finger  in  the  rectum  ;  and  likewife,  that 
it  can  never  be  applicable  where  the  fmus  runs  far- 
ther up  the  rectum  than  the  finger  can  reach  ;  and 
with  a  view  to  obviate  thefe  inconveniencies,  different 
iuftrumcnts  have  been  propofed,  paiticularly  a  direc- 
tor and  fcalpel. 

I'he  diredor,  which  ought  to  be  large,  being  paflk 
ed  into  the  rectum,  the  finus  or  fiftula  is  advifed  to  be 
laid  open  through  its  whole  length,  by  a  fcalpel  being 
made  to  run  along  the  whole  courfe  of  it  from  the 
external  opening  of  the  finus.  This,  I  mufl  obferve 
however,  is  a  practice  net  to  be  imitated  :  the  hazard 
attending  it  is  evidently  indeed  fo  great,  that  it  has 
feldom  been  attempted,  nor  will  it  probably  be  ever 
recommended  but  by  fuch  writers  as  copy  from  one 
another.  The  parts  chiefly  ailected  by  the  operation, 
lie  fo  contiguous  to  organs  that  ought  not  to  be  in- 
jured, particularly  to  the  bladder,  that  we  fnould  nev- 
er on  any  account  attempt  to  lay  finufes  in  this  fitua- 
tion  open,  unlefs  the  finger  is  previoufiy  introduced 
to  ferve  as  a  guide  for  the  biftourv  ;  and  for  the  fame 
reafon  the  inltrument  fhould  never  be  carried  faither 
than  the  length  of  the  finger.  Fiftulous  fores  do  not 
commonly  penetrate  deeper  here  than  the  length  of 
the  forefinger :  in  fome  cafes,  however,  they  go  to  a 


298  Of  the  Fijlida        Chap.  XXXVIII. 

greater  depth :  they  have  even  been  found  to  pafs  to 
the  very  fuperior  part  of  the  os  facrum,  and  acrofs  the 
pelvis  in  a  direction  between  the  reclum  and  bladder. 
In  every  fuch  inftance,  however,  all  that  an  operator 
fliould  attempt,  is  to  lay  the  under  part  of  the  fore 
completely  open,  fo  as  to  procure  as  free  and  eafy  a 
difcharge  to  the  matter  as  pofiible  ;  for  any  advantage 
to  be  derived  from  the  incifion  being  carried  to  a 
greater  depth  than  the  finger  can  reach,  would  feldom 
if  ever  compenfate  the  hazard  of  the  attempt  :  and 
whenever  the  fmufes  are  confined  to  the  under  part  of 
the  gut,  no  other  direftor  than  the  finger  is  required  ; 
for  whoever  has  done  the  operation  in  the  manner  I 
have  advifed,  will  find  that  the  redum  is  eafily  pierc- 
ed with  the  probe  pointed  biftoury,  and  that  it  may 
be  done  without  hurting  the  finger  previoully  pafTed 
into  the  gut. 

It  is  alleged  by  fome,  that  danger  may  occur  from 
fmufes  in  this  fituation  being  cut  freely  open  :  trou- 
blefome  h^morrhagies,  they  think,  may  happen,  from 
the  hsemorrhoidal  arteries  and  veins  being  cut ;  fo  that 
it  has  been  propofed  to  open  the  fmufes  with  ligatures  : 
by  inferting  one  end  of  a  piece  of  pliable  filver  or  lead 
along  the  courfe  of  a  finus,  pufhing  it  into  the  redum, 
drawing  it  out  at  the  anus,  and  twifting  the  ends  of  it 
together,  the  contained  parts  are  thus  directed  to  be 
gradually  compreffed  and  divided.  But  this  being 
not  only  more  painful,  but  alfo  more  tedious,  than 
the  method  of  dividing  thefe  parts  with  a  biftoury, 
and  as  we  have  few  inftances  of  the  hasmorrhagy  that 
enfues  from  this  operation  being  fevere,  the  latter  is 
very  univerfally  preferred  :  the  late  Mr.  Deifault  of 
Paris,  a  furgeon  of  much  eminence  and  refpedtability, 
conceived,  indeed,  a  partiality  for  the  method  of  cur- 
ing this  difeafe  with  a  ligature,  formed  of  lead  or  fil- 
ver wire,  and  he  contrived  a  very  ingenious  apparatus 
for  palfmg  the  lead  ;  but  for  the  reafons  that  I  have 
given,  there  is  no  reafon  to  fuppofe  that  it  will  ever 
be  much  employed  by  others. 


Chap.  XXXVIII.  in  Am,  299 

The  different  finufes  being  laid  open  with  the  bif- 
toury,  much  care  is  required  in  applying  the  dreffings, 
for  on  this  the  fuccefs  of  the  operation  in  a  great  mea- 
fure  depends.  Some,  however,  are  fo  inattentive  to 
this,  as  to  fuppofe  that  every  thing  neceifary  is  done, 
when  the  divifion  of  the  parts  is  completed  ;  but  this 
is  fo  far  from  being  the  cafe,  that  I  may  freely  affert, 
that  a  cure  will  feldom  be  obtained,  if  much  atten- 
tion be  not  given  to  the  fubfequent  treatment  of  the 
fores. 

The  parts,  however,  ought  not  to  be  much  cram- 
med with  drefllngs  ;  nor  ihould  any  thing  be  employ- 
ed that  is  not  perfectly  mild,  and  incapable  of  excit- 
ing much  irritation.  Dry  lint  is  almoft  the  only  ap- 
plication that  practitioners  ufe,  but  it  is  ill  fuited  for 
the  purpofe.  One  of  the  moft  diftrefsful  fymptoms 
that  enfues  to  this  operation,  is  diarrhoea,  attended 
with  tenefmus,  or  a  frequent  defire  to  go  to  (tool.  In 
fome,  the  divifion  of  the  fmufes  alone  appear  to  excite 
this  ;  but  it  very  commonly  may  be  traced  as  a  con- 
fequence  of  the  after  management  of  the  fores  :  for 
every  application  that  is  not  perfedly  mild,  and  efpe- 
cially  if  forcibly  pulhcd  to  the  bottom  of  the  wound, 
is  furc  to  induce  a  very  diilrefsful  degree  of  irritation 
in  the  end  of  the  gut  ;  and  as  this  almoft  always  ex- 
cites a  frequent  discharge  of  faeces,  that  not  only  tends 
to  reduce  the  ftrength  of  the  patient,  but  to  interrupt 
the  cure  of  the  fores,  it  becomes  highly  neceifary  to 
avoid  it. 

With  this  view,  inftead  of  dry  lint,  I  have  long  been 
in  the  praftice  of  ufmg  fine  thin  old  linen  dipped  in 
oil  or  fpread  with  any  fimple  mild  ointment ;  by  which 
we  with  certainty  avoid  that  diftrefsful  irritation  which 
dry  applications  to  fuch  fores  never  fail  to  induce. 
After  the  wounds,  therefore,  have  been  cleared,  a  very 
fmall  pledget  of  this  kind  of  linen,  thinly  covered  with 
fimple  liniment  of  wax  and  oil,  ftiould  with  the  end 
of  a  probe  be  gently  inferted  between  their  edges  ;  but 
not  to  fuch  a  depth,  or  with  fuch  force,  as  to  give  any 


300  Of  the  Fiftula        Chap.  XXXVIII. 

kind  of  uneafinefs.  This  being  done,  and  a  cufliion 
of  fine  tow,  covered  with  a  comprefs  of  foft  linen,  be- 
ing applied  over  the  parts,  and  fccured  \Yith  a  T  band- 
age, the  patient  fhould  be  carried  to  bed  ;  and  the 
dreliings  being  renewed,  either  after  every  ftool,  or, 
when  thefc  are  not  frequent,  once  in  the  twenty-four 
hours,  the  fore  will  in  general  fill  up  from  the  bottom, 
and  will  at  laft  cicatrize  in  the  fame  manner  as  wounds 
in  any  other  part.  This  kind  of  fore  fliould  indeed 
be  managed  in  every  rcfpccl  like  fimilar  fores  in  oth- 
er parts  of  the  body  :  for  although  fomething  myite- 
rious  or  peculiar  has  commonly  been  fuppofed  to  exiil 
in  fores  about  the  anus  ;  yet  this  is  by  no  means  the 
cafe  :  they  are  of  a  nature  exactly  fimilar  to  fores  in 
other  parts,  and  are  to  be  cured  at  all  times  by  the 
fame  means.  They  fhould  be  lightly  and  eafily  drelT- 
ed,  in  the  manner  I  have  advifed.  No  injections 
fliould  be  ufed,  as  is  often  done  with  a  view  to  cleanfe 
the  parts.  They  are  not  more  neceffary  here  than  in 
any  other  fore,  and  I  have  conftantly  feen  that  they 
do  harm.  They  not  only  irritate  and  inflame  the  parts 
to  which  they  are  applied,  but  if  ufed  v/ith  much  force, 
the  liquor  is  apt  to  find  its  way  into  the  contiguous 
cellular  fubftance,  and  in  this  manner  to  form  new 
finufes.  They  Ihould  in  no  inllance  therefore  be  em- 
ployed. 

I  have  already  obferved,  that,  by  perfeverance  in 
this  mild  courfe  of  treatment,  a  cure  will,  in  general, 
be  obtained.  But  in  fome  inilances  it  is  otherwife  ; 
and  inftead  of  a  good  difcharge,  and  red  frefh  granu- 
lations, with  v/hich  the  wound  in  a  healing  flate  ought 
to  be  covered,  the  parts  become  foft,  flabby,  and  un- 
healthy, and  the  matter  is  thin,  fetid,  and  perhaps  mix- 
ed with  blood.  If,  on  a  minute  infpeftion  of  the  fore, 
any  part  of  a  finus  is  found  to  have  efcaped  notice, 
and  if  matter  is  found  to  lodge  in  it,  a  certain  and  al- 
mofl:  immediate  advantage  will  be  derived  from  laying 
it  open  to  the  bottom.  The  moll  frequent  caufe  of 
failure  indeed  in  this  operation  is  want  of  attention  to 


Chap.  XXXVIIT.  in  Ano.  301 

this  very  neceflary  point  ;  in  the  firfl  place,  by  due 
pains  not  being  taken  to  difcover  the  finufes  in  the  time 
of  the  operation,  and  a  delire  afterwards  to  perform 
the  cure  by  any  other  means  rather  than  put  the  pa- 
tient to  the  pain  of  another  operation,  or  candidly  to 
avow  our  own  error,  which  in  every  inflance  fhould 
freely  be  done.  I  readily  own,  that  when  I  firft  fet- 
tled in  bufmefs,  I  fell  into  this  error,  in  diilerent  in- 
flances  :  by  not  fearching  with  fuflicient  pains  after 
the  firft  incifion  was  made,  finufes  efcaped  notice  that 
might  have  been  difcovered  :  but  having  long  been 
cbnvinced,  that  a  patient  had  better  be  kept  much 
longer  on  the  table,  fo  as  to  have  all  the  parts  exam- 
ined in  th*^  moft  accurate  manner,  than  to  incur  the 
rifk  of  a  fecond  operation,  I  now  fpend  fo  much  time 
upon  this,  that  in  the  courfe  of  thelc  eighteen  or  twen- 
ty years,  fcarcely  an  inftance  has  occurred  with  me, 
out  of  fome  hundred  cafes,  of  the  operation  being  from 
this  caufe  to  be  repeated  :  1  own,  however,  that  more 
time  is  for  this  purpofe  fpent  on  the  operation  than  is 
commonly  done. 

It  fometimes,  again,  happens,  that  the  cure  of  the 
fore  is  retarded,  not  by  any  fault  in  the  operation,  but 
by  real  difeafe  of  the  lyftem  :  in  this  cafe,  if  the  pa- 
tient is  found  to  labour  under  lues  venerea,  fcrofula, 
or  fcurvy,  the  remedies  appropriated  to  the  exifting 
difeafe  fliould  be  prefcribed  ;  or  if  the  conftitution  is 
merely  relaxed  or  Vv'eakened,  whether  by  fever  or  any 
other  caufe,  the  natural  tone  of  the  fyllem  (hould  be 
reftored,  by  a  nourifliing  diet,  a  proper  allowance  of 
wine,  and  refidence  in  good  air. 

When  treating  of  ulcers  in  Chapter  V.  I  have  en- 
deavoured to  inculcate  the  utility  of  iifues  in  every  va- 
riety of  fore  ;  but  in  no  variety  of  the  uileafe  does  this 
remedy  a£l  with  more  advantage  than  in  the  fiftula  in 
ano,  efpecially  when  the  difcharge  has  been  of  long  du- 
ration. Different  inftances,  indeed,  have  occurred  to 
me,  in  which,  vhere  iffues  are  not  inferted,  the  patient 
tvas  obvioufly  injured  by  curing  the  difeafe  :  other  dif- 


302  OfibeFiJlula        Chap.  XXX VIIL 

eafes  of  a  more  alarming  nature  were  induced  by  it ; 
while  in  fome  I  have  not  been  able  to  obtain  a  perma- 
nent cure  of  the  fmus  till  an  ifl'ue  was  inferted  :  I  am 
now  therefore  fo  much  convinced  of  the  utility  of  if- 
fues,  that  whenever  the  difeafe  has  been  of  long  dura- 
tion, and  the  difcharge  copious,  I  feldom  advife  the 
operation  till  an  iilue  is  inferted. 

Hitherto,  I  have  been  fuppofmg,  that  the  difeafe  has 
not  advanced  farther  than  to  produce  finufes  along  the 
courfe  of  the  re£tum,  and  parts  immediately  contigu- 
ous. We  fliall  now  proceed  to  confider  it  in  its  more 
advanced  ftages. 

The  firft  of  thefe  that  I  fliall  notice,  is  that  in  which 
the  parts  lying  contiguous  to  the  fores,  have  been  fep- 
arated  or  detached  from  each  other,  by  a  mere  effu- 
fion  of  matter  into  the  furrounding  cellular  fubftance. 
This,  to  a  certain  degree,  is  the  cafe  in  every  fmus  ; 
but  when  fmufes  about  the  anus  have  been  of  long  du- 
ration, the  matter  which  they  produce,  if  it  does  not 
find  a  free  outlet,  fpreads  in  fome  inftances  fo  exten- 
fively  among  the  contiguous  parts,  as  to  feparate,  not 
only  all  the  fkin  and  other  teguments  from  the  muf- 
cles  underneath,  but  to  detach  all  the  under  part  of 
the  reftum  from  the  cellular  fubftance  with  which,  in 
a  (late  of  health,  it  is  firmly  conneded.  Of  this  I 
have  now  met  with  various  inftances. 

In  this  ftate  of  the  difeafe,  two  modes  of  operating 
have  been  advifed  ;  either  to  take  away  a  confiderable 
portion  of  the  teguments,  fo  as  to  give  free  vent  to  the 
matter  ;  or,  if  this  does  not  prove  fuccefsful,  to  extir- 
pate all  the  inferior  part  of  the  re£tum  that  is  found 
to  be  feparated  from  the  contiguous  parts. 

Thefe  operations,  however,  not  only  give  fevere 
temporary  pain,  but  much  fubfequent  diitrefs  ;  and  as 
all  the  advantages  that  arife  from  them  may  be  attain- 
ed in  a  more  eafy  manner,  they  ought  undoubtedly 
to  be  laid  afide.  To  take  away  any  large  portion  of 
the  teguments  about  the  anus,  mull  of  itfelf  be  ex- 
tremely painful  J   and  to  extirpate  the  extremity  of 


Chap.  XXXVIII.  in  Am.  303 

the  reclum,  would,  in  a  great  proportion  of  cafes,  be 
produftive  of  more  mifery  than  could  ever  be  induced 
by  a  continuance  of  the  difeaie  ;  for,  befides  the  diffi- 
culty and  pain  that  in  this  fituation  would  arife  from 
the  paflage  of  hard  f?eces,  it  would  be  impoflible  for 
tho  patient  to  retain  liquid  (tools. 

This  diflrefsful  operation,  however,  need  never  be 
put  in  practice ;  for  I  know  from  various  trials,  that 
a  fnnple  divifion  of  the  gut  will  with  jnore  certainty 
accomplifn  a  cure  :  all  that  ought  to  be  done  there- 
fore is,  to  lay  the  detached  portion  of  gut  open  from 
one  end  to  the  other  in  the  manner  I  have  already 
pointed  out  in  cafes  of  fnnple  fmus  :  and  if  this  does 
not  allow  the  gut  to  apply  equally  to  the  contiguous 
parts,  another  incifion  Ihould  be  made  on  the  oppo- 
lite  fide  of  it ;  by  which  means  all  fuch  parts  of  it  as 
were  feparated  or  detached  from  the  furrounding  muf- 
cles  will  now  be  equally  applied  to  them  ;  no  part  of 
it  will  be  puckered  or  unequal  ;  and  ii;  the  neighbour- 
ing bones  and  other  parts  are  found,  and  the  conftitu- 
tion  not  difeafed,  a  cure  will  foon  be  obtained  by  ad- 
hefion  again  taking  place  between  the  gut  and  parts 
that  lie  behind  it. 

Upon  the  fame  principles  that  in  this  fituation  we 
advife  a  divifion  of  the  rectum,  when  the  matter  has 
paffed  between  the  fkin  and  mufcles  of  the  perinscum, 
or  of  the  hips,  the  bag  in  which  it  is  contained  fliould 
be  freely  laid  open  from  one  end  to  the  other  ;  and  if 
one  incifion  is  not  fufficient,  another  fliould  be  made 
without  delay  :  the  fame  drellings  fliould  be  applied 
here  that  I  have  already  advifcd  where  the  finus  runs 
behind  the  re6tum. 

Hitherto  I  have  fuppofed  that  the  fiftula  or  finus 
difcharges  its  contents  by  one  or  more  external  open- 
ings in  the  neighbourhood  of  the  anus  :  this,  howev- 
er, does  not  always  happen  ;  and  the  matter,  inftead 
of  being  difcharged  by  an  external  opening,  is  in  fome 
inflances,  firft  emptied  into  the  gut,  and  afterwards 
difcharged,  either  by  itfelf,  or  mixed  with  faeces  on  the 


504  Of  the  Tijlida         Chap.  XXXVIII. 

patient  going  to  flool.  This,  as  I  have  already  obferv- 
ed,  forms  what  has  been  termed  an  occult  fillula,  or, 
according  to  French  authors,  une  fillule  borgne. 

As  the  ufual  and  mo(t  certain  characleriltic  of  fif- 
tula,  namely,  an  external  opening  difcharging  matter, 
is  here  wanting,  fome  attention  is  required  to  afcertaiii 
its  exiftence,  as  well  as  to  prevent  it  from  being  con- 
founded with  other  difeafes.  Thus,  matter  difcharg- 
ed  from  abfcefles  in  the  upper  part  of  the  alimentary 
canal,  has,  in  fome  inftances,  been  fuppofed  to  proceed 
from  an  occult  fiflula  in  the  neighbourhood  of  the 
anus  ;  and  vice  versa,  pus  collefted  in  and  difcharged 
from  an  impoflhume  near  to  the  anus,  has,  merely 
from  want  of  attention,  been  fuppofed  to  originate 
from  difeafe  in  the  upper  part  of  the  gut ;  and  upon 
this  fuppofition,  remedies  have  been  prefcribed  with- 
out effect,  when  a  complete  cure  might  have  been  ob- 
tained by  very  fimple  means. 

The  diftinction,  however,  between  thefe  difeafes  is, 
in  general,  fufficiently  evident.  When  matter  colleft- 
ed  in  the  fuperior  part  of  the  gut,  is  at  laP:  difcharged 
by  ftool,  it  is  commonly  thoroughly  mixed  with,  and 
feems  to  conftltute  a  part  of,  the  fseces,  and  no  pain 
takes  place  near  to  the  anus.  But  in  the  cafe  of  an 
occult  fiilula,  the  matter  difcharged  by  ftool  is  not 
mixed  with  the  faeces  ;  on  the  contrary,  they  always 
appear  diftinct  and  feparate  ;  on  minute  inveftigation, 
fome  degree  of  hardnefs,  fvvelling,  or  difcoloration,  is 
always  difcovered  near  to  the  fundament ;  and  in  this 
fpot  a  confiderable  degree  of  pain  is  felt  on  prelTure. 

Various  means  have  been  propofed  in  cafes  of  oc- 
cult fiftula,  for  difcovering  the  fite  of  the  abfcefs.  By 
fome  we  are  advifed  to  pafs  a  curved  probe  up  the 
rectum  ;  and  to  fearch  with  the  point  of  it  till  the 
opening  is  difcovered,  when  by  pufhing  it  forward,  it 
may  pafs  into  the  abfcefs  :*  others,  again,  advife  a 
thick  firm  tent  to  be  pufhed  into  the  redum,  fo  as  to 

•  vide  Dioiiis — Courfc  of  Operations,  Demonftr.  ir. 


Chap.  XXXVIII.  in  Am.  305 

obftrucl  every  means  of  communication  between  the 
fmus  and  gut ;  and  by  this  they  fuppofe,  that  the 
matter  of  the  abfcefs  may  be  made  to  colledl  in  fuch 
quantities  as  evidently  to  point  out  its  fituation.  Nei- 
ther of  thefe  methods,  however,  are  neceflary,  nor  is 
it  piobable  that  they  would  often  fuccecd. 

Whenever  an  abfcefs  is  feated  near  to  the  verge  of 
the  anus,  however  fmall  it  may  be,  it  may  be  eafily 
difcovercd  :  for,  fome  degree  of  hardnefs,  a  fmall  tu- 
mefaftion,  and  moft  frequently  fome  difcoloration,  is 
obferved  at  fome  part  contiguous  to  the  extremity  of 
the  gut ;  and  whenever  this  mark  is  perceived,  and 
efpccially  if  prefl'ure  excites  much  pain,  there  will  be 
no  caufe  to  doubt  of  this  being  the  feat  of  the  abfcefs. 

In  fuch  circumftances,  what  are  we  to  do  ?  We 
ought  here  to  have  the  fame  objedt  in  view,  as  if  the 
matter  had  been  difcharged  by  an  external  opening  : 
for  the  difeafe  is  in  reality  the  fame,  and  differs  only 
in  this  fmgle  circumftance  from  the  moil  frequent 
variety  of  fiflula,  that  the  matter  is  in  this  cafe  firfl 
thrown  into  the  reftum,  before  it  can  be  difcharged, 
inftead  of  coming  freely  off  by  one  or  more  external 
outlets  near  to  the  anus.  And  as  the  two  varieties  of 
the  difeafe  are  very  nearly  the  fame,  fo  the  means  ne- 
ceffary  for  their  removal  are  very  fmiilar. 

As  foon  as  we  have  determined  to  perform  the  op- 
eration, the  point  of  a  lancet  fliould  be  plunged  into 
the  tumefied  or  difcoloured  fpot ;  and  upon  the  point 
of  the  inflrument  reaching  the  abfcefs,  which  is  at 
once  known  by  a  difcharge  of  pus  taking  place,  as  the 
difeafe  is  thus  reduced  to  the  ft  ate  of  a  fimple,  com- 
plete fiftula,  the  operation  is  to  be  finiflied  in  the  fame 
manner  as  I  have  already  advifed  for  that  variety  of 
the  difeafe  ;  by  the  introduction  of  the  finger  of  the 
left  hand  into  the  anus,  paffmg  the  probe  pointed  bif- 
toury  in  at  the  wound  newly  made,  and  on  its  poin( 
being  difcovered  by  the  finger  in  the  redum,  by  draw- 
ino;  it  out  in  fuch  a  manner  as  to  divide  the  abfcefs  or 

Vol.  III.  W 


3o6  Of  the  Fiftula        Chap.  XXXVIII. 

fmus  through  its  whole  length  ;  and  the  fubfequent 
treatment  of  the  fore  is  alfo  the  fame  as  in  other  cafes 
of  fiftula. 

All  that  has  been  as  yet  faid  relates  to  the  mildeft 
and  moft  fimple  ftages  of  filtula  ;  the  parts  chiefly 
affefted  being  fuppofed  to  be  in  no  other  way  difeaf- 
ed,  than  by  having  an  abfcefs  feated  in  them,  either 
occult,  or  with  one  or  more  external  fmufes  running 
into  it.  But  when  by  neglecl,  or  improper  treatment, 
the  matter  collected  hi  fuch  abfceffes  does  not  find  a 
free  vent,  the  contiguous  parts  inflame,  become  pain- 
ful, and  in  a  gradual  manner  acquire  much  morbid 
hardnefs  or  callofity. 

In  fuch  circumftances,  various  remedies  have  been 
advifed  :  as  a  previous  ftep  to  any  operation,  it  has 
been  propofed  by  fome  to  diffolve  this  hardnels  or  cal- 
lofity, by  the  ufe  of  mercury,  aided  by  fuppurative  or 
emollient  poultices.  Others  advife  the  hardened  parts 
to  be  deftroyed  with  cauftic  ;  but  the  opinion  that 
has  till  of  late  moft  generally  prevailed,  is,  that  all  the 
callous  parts  fhould  be  extirpated  with  the  fcalpel. 

But  whoever  has  had  opportunities  of  becoming 
acquainted  with  this  branch  of  practice,  will  know, 
that  it  is  perfedly  impoflible  to  dilfolve  or  diflipate 
any  callofity  that  has  been  of  long  duration,  either  by 
poultices,  mercurials,  or  other  difcutients  ;  and  it 
luckily  happens,  that  a  cure  may  in  general  be  ob- 
tained by  means  of  a  more  gentle  nature  than  the 
deftruclion  of  the  hardened  parts,  whether  by  cauftic 
or  extirpation  :  when  the  parts  cannot  be  preferved 
but  at  the  hazard  of  the  patient's  life,  they  ought 
undoubtedly  to  be  removed  ;  but  as  neceftity  alone 
jfhould  point  out  the  propriety  of  fuch  a  painful  and 
violent  meafure,  it  ftiould  never  be  advifed  when  our 
views  can  be  accompllftied  in  a  milder  manner. 

I  have  endeavoured  to  fhew,  and  indeed  the  fa£l  is 
obvious  to  all  who  will  be  at  the  trouble  of  obferving, 
that  the  callous  ftate  of  the  parts  that  often  takes  place 
where  the  difeafe  has  been  of  long  duration,  is  uni- 


Chap.  XXXVIII.  in  Ano,  307 

formly  the  effedt  of  the  matter  not  findhig  a  free  vent, 
and  of  its  being  thereby  forced  to  difperfe  among  the 
contiguous  mufcles  ;  by  which,  pain,  inflammation, 
and  hardnefs,  are  fucceflively  and  neceilarily  pro- 
duced. 

If  this  is  a  true  flate  of  the  matter,  and  all  prafti- 
tioners  of  experience  will  probably  admit  that  it  is  fo, 
it  mufl  be  obvious,  that  there  can  be  no  need  of  luch 
violent  remedies  as  thofe  I  have  mentioned,  namely, 
the  removal  of  the  difeafed  parts  either  with  cauftic  or 
the  fcalpel  :  the  means  of  relief  to  be  employed  here, 
are  merely  fuch  as  will  afford  a  free  outlet  to  the  mat- 
ter, whilft  they  alfo  ferve  to  induce  and  preferve  a 
difcharge  of  matter  in  the  fubltance  of  the  difeafed 
parts,  and  which  ]  am  inclined  to  confider  as  the  mod 
effectual  method  hitherto  difcovered  for  the  removal 
of  all  fuch  morbid  callofities. 

Through  the  whole  of  this  chapter,  I  have  avoided 
the  ufe  of  the  word  fchirrus  ;  and  I  am  here  particu- 
larly anxious  to  have  it  remarked,  that  I  have  done 
fo  :  for  in  real  fchirrus,  the  remedy  I  have  now  point- 
ed out,  namely,  the  excitement  of  fuppuratlon  in  the 
fubftance  of  the  difeafed  parts,  would  probably  prove 
highly  pernicious,  by  forcing  quickly  forward  to  a 
ftate  of  cancer,  a  tumor,  which,  if  left  to  itfelf,  might 
probably  have  remained  indolent  for  a  great  length  of 
time.  It  is  therefore  evident,  that  an  accurate  diflinc- 
tion  between  real  fchirrus,  and  other  hard  tumors,  is 
a  point  of  much  moment.  Every  hard  tumor  that 
from  experience  is  known  to  be  apt  to  degenerate  in- 
to cancer,  I  would  denominate  fchirrus.  Now,  we 
know  very  well,  that  cancers  rarely  attack  tumors  that 
are  not  glandular  :  fo  that  to  every  indurated  fwelling 
of  the  cellular  fubftance,  and  other  foft  parts  not  evi- 
dently glandular,  a  different  appellation  fliould  be  giv- 
en :  all  of  thefe  may,  with  propriety  enough,  be  de- 
nominated callous  tumors. 

Thofe  hard  tumefactions,  therefore,  feated  in  the 
cellular  fubftance  near  the  anus,  as  they  never  appear 
w  2 


3o8  Of  the  Tijhila        Chap.  XXXVIII. 

to  degenerate  into  cancer,  I  have  termed  callofities  : 
the  moil  effeclual  remedy  that  I  have  tried  for  the 
removal  of  thefe,  is  a  free  fuppuration  induced  in 
them ;  and  the  beft:  method  of  eftedling  this,  is  by 
laying  every  fmus  that  can  be  difcovered,  freely  open 
from  one  end  to  the  other  ;  and  when  the  finufes  are 
not  numerous,  it  proves  even  uieful  to  make  one, 
two,  or  more  deep  incifions  along  the  whole  extent  of 
the  induration.  By  carrying  the  incifion  to  the  full 
depth  of  the  indurations,  fuch  a  plentiful  flow  of  mat- 
ter enfues  to  the  inflammation  that  they  induce  at  firfl, 
as  commonly  acts  with  much  advantage  in  the  cure. 

Indeed  none  can  imagine  how  highly  beneficial  this 
practice  proves,  but  thofe  who  have  experienced  the 
benefit  that  enfues  from  it  :  in  various  inflances,  I 
have  known  it  fiicceed  completely  where  the  total  re- 
moval of  the  difeafed  parts  had  previoufly  been  judg- 
ed to  be  indifpenfable.  Where  the  difeafe  has  been 
of  long  duration,  the  remedy  muft  indeed  be  long  per- 
fifled  in  ;  that  is,  a  plentiful  difcharge  of  pus  mufi  be 
long  preferved,  either  in  the  incifions  firfl  made,  or, 
if  thefe  heal  too  quickly,  in  others  made  to  fucceed 
them. 

In  fome  inflances,  thefe  incifions  do  not  eafily  fup- 
purate  ;  their  edges  inflame,  become  painful,  and  dif- 
charge a  thin  fetid  matter.  When  this  proceeds  from 
lues  venerea,  or  any  other  difeafe  of  the  confl:itution, 
this  mufl  be  firfl  removed,  before  the  incifions  will 
yield  good  matter.  But  when  the  fyftem  is  otherwife 
healthy,  and  when  there  is  therefore  reafon  to  ima- 
gine that  the  untoward  ftate  of  the  fores  proceeds 
merely  from  irritation,  or  fome  other  local  affeftion, 
in  fuch  circumflances,  Avarm  poultices  prove  highly 
ufeful :  by  their  emollient  properties,  they  tend  to  re- 
move irritation  with  more  effect  than  any  other  reme- 
dy ;  and  I  have  elfcwhere  fhewn,  that  nothing  ads 
with  fuch  certainty  in  the  formation  of  good  pus. 

In  every  cafe,  therefore,  of  fiftula,  attended  with 
much  hardnefs  and  tumefaction  of  the  contiguous 


Chap.  XXXVIII.  in  Atio.  309 

parts,  inftead  of  removing  the  hardened  parts  either 
with  cauflic  or  the  knife,  the  pradice  I  would  advife 
is  this  :  the  finus  or  fiflula  lliould  be  treated  in  the 
fame  manner  as  if  no  hardnefs  exifted  ;  that  is,  it 
fhould  be  laid  freely  open  from  one  end  to  the  other : 
if  more  finufes  are  difcovcred,  thefe  fhould  alfo  be 
laid  open  ;  and  if  the  hardnefs  in  the  contiguous  parts 
extends  either  laterally,  or  in  any  other  direftion  be- 
yond the  courfe  of  the  finufes,  one  or  more  deep  in- 
cifions  fliould  be  made  along  the  whole  length  of  it: 
and  by  preferring  thefe  incifions  in  a  fuppurative  (late 
till  the  hardnefs  is  difcufled,  they  may  then  be  allow- 
ed to  heal  from  the  bottom  in  the  fame  manner  with 
wounds  or  ulcers  induced  by  any  other  caufe. 

By  this  management  alone,  when  the  conftitution 
is  otherwife  healthy,  the  very  word  variety  of  fiflula 
may  be  cured  with  more  certainty,  and  with  much 
more  comfort  to  the  patient,  than  by  the  extirpation 
of  the  hardened  parts.  Indeed,  fcarcely  any  cafe,  I 
think,  can  occur,  of  the  parts  being  in  fuch  a  flate  as 
to  render  it  proper  to  remove  ihem,  if  they  have  not 
been  long  and  almoft  entirely  feparated  from  the  fub- 
jacent  mufcles,  with  which,  in  a  healthy  flate,  they 
ought  to  be  connected.  This,  again,  can  never  take 
place,  but  from  very  grofs  mifmanagement :  when  we 
do,  however,  meet  with  it,  and  when  the  hardened 
parts  are  fo  much  detached  from  the  others,  that  they 
would  not  probably  adhere  again,  neceflity  points  out 
the  propriety  of  cutting  them  oft';  and  in  external  ul- 
cerations of  thefe  parts,  when  the  edges  of  the  fores 
have  become  hard  and  reverfed,  the  cure  may  be  pro- 
moted by  removing  the  difeafed  parts  ;  but  in  no  oth- 
er inflance  ought  this  pradice  to  be  attempted ;  for 
all  the  advantages  faid  to  be  derived  from  it,  may  be 
obtained  with  much  more  eafe  and  fafety  from  the 
method  of  cure  I  have  here  pointed  out. 

The  only  other  fymptoms  connected  with  fiflula  in 
ano,  to  which  I  have  not  yet  adverted,  are  fuch  aS 


310  Of  the  Fijluh        Chap.  XXXVIII. 

atife  from  afFedions  of  deep  feated  parts  ;  namely, 
fuch  as  proceed  from  difeafe  of  the  os  coccyx,  os  fa- 
crum,  bladder,  and  parts  about  the  loins. 

It  fometimes  happens,  that  the  matter  collefted  hi 
fiftulous  fores  about  the  anus,  by  being  allowed  to 
fpread  among  the  neighbouring  parts,  comes  at  laft 
even  to  injure  the  bones  themfelves  ;  but  inftances 
likewife  occur  of  difeafes  of  the  bones  being  the  pri- 
mary affedlion,  and  of  its  giving  rife  to,  inllead  of  be- 
ing produced  by,  fmufes  about  the  reftum.  Thus, 
collections  of  matter  on  the  pfose  mufcles,  originating 
in  fome  inftances,  from  caries  of  the  lumbar  vertebrae, 
inftead  of  falling  down  and  pointing,  as  they  com- 
monly do,  in  the  upper  and  forepart  of  the  thigh,  are 
fometimes  found  to  follow  the  courfe  of  the  inteftines, 
and  to  difcharge  their  contents  at  the  fide  of  the  rec- 
tum. A  fevere  bruife,  too,  upon  the  hips  and  conti- 
guous parts,  by  injuring  the  os  coccyx,  has  in  fome 
inftances  produced  the  fame  effedt. 

But  the  moft  diftrefsful  circumftance  that  ever  ac- 
companies fiftula  in  ano,  is  the  formation  of  a  pafl'age 
between  the  rectum  and  bladder.  This  fometimes 
happens  indeed,  where  no  fmus  or  abfcefs  had  previ- 
oufly  appeared  about  the  anus  ;  but  it  more  frequent- 
ly fucceeds  to  ulceration  in  thefe  parts,  and  by  thefe 
being  improperly  treated,  than  to  any  other  caufe. 
The  fymptoms  by  which  the  exiftence  of  this  dread- 
ful malady  is  with  moft  certainty  known,  are,  in  the 
firft  place,  an  unufual,  dark  brown,  thick  fediment, 
being  obferved  in  the  urine,  which  by  degrees  becomes 
of  a  darker  colour,  and  of  a  more  offenfive  faecal 
fmell ;  air  is  frequently  difcharged  in  confiderable 
quantities  by  the  urethra,  both  before  and  after  void- 
ing urine ;  and  in  the  latter  ftages  of  the  difeafe,  the 
urine  does  not  get  a  free  vent  from  the  bladder. 

The  exiftence  of  thefe  fymptoms,  ferves  fufficiently 
to  afcertain  the  nature  of  the  difeafe ;  but  hitherto  we 
have  not  been  able  to  difcover  any  means  of  removing 


Chap.  XXXVIII.  in  Ano.  3 1 1 

it.  So  that  all  who  have  yet  been  attacked  with  it 
have  at  laft  fallen  viftims,  after  dragging  on,  twelve, 
eighteen  months,  or  perhaps  a  few  years  of  a  mifera- 
ble  exiftence. 

In  the  event  of  any  of  the  bones  of  the  coccyx,  fac- 
'rum,  or  lumbar  vertebras,  becoming  carious,  from  the 
matter  in  this  difeafe  having  been  allowed  to  penetrate 
and  to  corrode  them,  all  that  art  can  do  is  to  preferve 
a  free  vent  for  the  difcharge  ;  to  keep  the  parts  clean  ; 
to  extradl  any  pieces  of  lool'e  bone  that  may  be  diff 
covered  ;  and  to  flrengthen  the  conftitution  by  a  nou- 
rifhing  regimen,  with  a  view  to  enable  it  to  fupport 
the  long  continued  difcharge  to  which  it  may  proba- 
bly be  expofed  :  fome  few  have  in  fuch  circumflances, 
and  with  fuch  a  plan  of  management,  been  fortunate 
enough  to  obtain  cures,  by  fuch  pieces  of  bone  as  were 
fpoiled  being  at  lad  thrown  off,  and  by  the  parts  be- 
ing then  induced  to  heal.  This,  it  mufl  be  confelfed, 
however,  is  a  rare  occurrence  ;  and  all  that,  in  this 
fituation,  we  have  rcafon  to  expect,  is  to  be  able  to 
palliate  the  moil  diftrefsful  fymptoms. 

I  have  thus  concluded  what  it  was  my  intention  to 
offer  on  the  fiftula  in  ano  ;  and  as  it  is  a  very  diftrefs- 
ful as  well  as  a  frequent  difeafe,  and  efpecially  as  it  was 
never  till  of  late  defcribed  with  accuracy,  I  have  hence 
been  induced  to  confider  it  more  minutely  than  I  oth* 
erwife  fliould  have  done.  What  I  have  endeavoured 
to  fliew,  and  to  which  I  ftill  wifti  to  excite  the  atten- 
tion of  the  younger  part  of  the  profellion,  is,  that  a 
fnius  or  fiftula,  is  a  difeafe  of  the  very  fame  nature  in 
the  neighbourhood  of  the  anus,  as  in  any  other  part 
of  the  body  ;  and  therefore,  that  the  method  of  cure 
ought  to  proceed  upon  the  fame  principles  here  as  in 
fmiilar  affections  of  other  parts.  Till  the  late  improve- 
ments made  in  the  treatment  of  this  difeafe,  and  till 
the  true  nature  of  it  was  underftood,  much  confufion 
fubfifted  in  the  method  of  conducing  the  cure.  Ex- 
cept in  the  mod  trifling  cafes  of  fuperftcial  finufes,  it 


312  Of  ihe  Fijiula        Chap.  XXXVIII. 

was  never  Imagined  that  a  fimple  incifion  could  an- 
fvver  :  nothing  lefs  than  a  total  deftrudion  or  removal 
of  the  difeafed  parts  was  fuppofed  to  be  fufficient. 

But  it  will  now,  1  hope,  appear,  that  this  is  very 
rarely  neceflary  ;  and  when  a  cure  is  practicable,  that 
it  will  be  more  readily  accompliflied  by  the  means  I 
have  pointed  out,  namely,  by  a  mere  divifion  of  the 
fmufes,  than  by  any  other  that  has  yet  been  propofed. 
It  will  fometimes  happen,  indeed,  that,  in  cafes  of  an 
inveterate  nature,  none  of  the  means  that  I  have  men- 
tioned will  fucceed ;  but,  in  all  fuch  cafes,  no  advan- 
tage would  be  derived  from  more  violent  remedies, 
and  much  diftrefs  would  certainly  be  induced  by  them. 

I  have  already  obferved,  that  the  beft  form  of  knife 
that  I  have  yet  feen  for  fiftula  in  ano,  is  one  or  other 
of  the  biftouries,  delineated  in  Plate  LXIV.  Thofe 
who  are  not  accuftomed  to  ufe  this  bifloury,  are  apt 
indeed  to  fuppofe,  that  it  cannot  penetrate  the  re£tum 
but  with  much  rilk  of  injury  to  the  finger  of  the  op- 
erator, previoully  palled  into  the  gut ;  but  this  is  fo 
far  from  being  the  cafe,  that  in  none  of  the  cafes  in 
which  I  have  operated,  and  they  now  amount  to  feme 
hundreds,  has  my  finger  ever  been  hurt :  with  a  view, 
however,  to  obviate  this  difficulty,  a  very  neat  and 
fnnple  invention  has  for  fome  years  pad  been  ufed  by 
many,  and  of  which  I  have  given  a  figure  in  Plate 
CXIV.  fig.  2.  and  3.  and  the  mode  of  applying  it  will 
be  feen  in  the  explanation  of  the  Plate.  The  probe 
pointed  bifloury,  however,  when  properly  formed,  di- 
vides the  gut  in  a  great  proportion  of  cafes  with  per- 
fedl  cafe,  and  with  no  hazard,  as  I  have  endeavoured 
to  fliew  either  to  the  patient  or  operator  ;  but  where 
the  parts  meant  to  be  cut  are  of  confiderable  thicknefs, 
as  is  the  cafe  when  the  finus  does  not  run  contiguous 
to  the  rectum,  I  have  fometimes  found  it  difficult  to 
perform  the  operation  with  a  biftoury  of  any  form. 
The  difficulty,  however,  does  not  confifl;  in  palling  the 
inftrument  from  the  finus  into  the  redum,  which,  with 


Chap.  XXXVIII.  in  Ano,  3 1  % 

the  common  crooked  biftoury,  is  in  every  cafe  eafily 
done,  if  the  probe  pointed  part  of  it  is  properly  made, 
but  in  turning  the  point  of  it  down,  fo  as  to  divide  the 
parts  from  the  opening  at  which  it  entered,  to  the  un- 
der part  of  the  gut :  by  cutting  flowly  and  dehberate- 
ly,  I  have  always  been  able  to  do  it ;  but  in  one  cafe, 
a  biftoury  of  confiderable  ftrength  broke  while  I  was 
making  the  cut ;  and  in  different  inftances  I  have 
known  this  happen  with  others :  this  has  made  me 
wifh  to  have  an  inllrument  for  this  operation  dill  more 
perfeft  than  the  biftoury :  many  have  been  propofed, 
but  none  that  has  yet  appeared  anfwer  fo  well  as  the 
biftoury  :  I  am  at  prefent  ufmg  fciffars  of  a  particular 
conftruftion  ;  but  I  cannot  as  yet  fpeak  of  them  with 
fuch  certainty  from  experience,  as  to  render  it  proper 
to  lay  them  before  the  public,  which,  however,  I  ftiall 
do  at  fome  future  period,  if  the  trials  that  I  mean  to 
give  them  fliall  juftify  the  opinion  I  have  formed  of 
them  :  I  may  here,  however,  fliortly  obferve,  that  they 
confift  of  two  cutting  blades,  which,  after  being  intro- 
duced feparately,  the  one  into  the  fmus,  and  the  other 
on  the  finger  previoufly  pafled  into  the  reftum,  are 
joined  at  their  axis  by  a  moveable  pin,  in  which  ftate 
being  able  to  aft  like  common  fciffars,  the  operation 
is  finiihed  by  a  fmgle  cut. 


314  General  Obfervations       Chap.  XXXK 


CHAPTER     XXXIX. 

OF  FRACTURES, 

SECTION  I. 

General  Obfervations  on  Fra&ures. 

SOME  praftitloners  denominate  every  folutlon  of 
continuity  in  a  bone,  a  fracture  ;  but  the  term  may, 
with  more  propriety,  be  confined  to  divifions  in  bones 
produced  by  external  violence.  Thus,  we  do  not  fay 
that  a  bone  is  fractured,  the  parts  of  which  are  fepa- 
rated  from  each  other  by  the  effect  of  internal  difeafe  ; 
while  we  fay  that  it  is  fractured  when  this  happens 
from  a  fall,  a  blow,  or  a  bruife. 

Fradtures  are  of  various  kinds,  and  are  diflinguifli- 
ed  by  different  names.  A  bone  may  be  fractured  ei- 
ther dire£tly  acrofs  ;  in  an  oblique  direction  ;  or  lon- 
gitudinally :  hence  the  terms,  tranfverfe,  oblique,  and 
longitudinal  fractures.  When  a  bone  is  fplit,  we  fay 
that  it  is  fplintered. 

When  the  teguments  remain  found,  a  fracture  of  a 
bone  is  denominated  fimple  ;  and  we  term  it  com- 
pound when  the  fracture  communicates  with  a  wound 
in  the  fliin  and  other  correfponding  foft  parts.  By 
fome  a  fracture  is  faid  to  be  compound  when  a  bone 
is  broken  into  different  parts  ;  and  thofe  fra£tures  they 
term  complicated,  that  are  accompanied  with  wounds 
in  the  correfponding  foft  parts.  This  fubdivifion, 
however,  of  fractures,  feems  to  be  unneceffary  :  for 
unlefs  a  bone  is  fplintered,  no  effential  difference  arifes 
merely  from  its  being  broken  at  one  or  two  parts  ; 
whereas  the  flighted  communication  between  a  frac- 
ture and  a  wound  in  the  furrounding  foft  parts,  chang- 


Se6t.  I.  on  FraHurcs,  315 

cs  the  nature  of  it  fo  entirely,  as  often  to  induce  much 
danger  where  no  alarming  fymptoms  would  otherwifc 
have  been  dreaded. 

The  exiftence  of  fracture  is,  for  the  mod  part,  eafi- 
ly  difcovered,  by  manual  examination.  A  fradlure  of 
a  lingle  bone,  where  there  is  only  one  in  the  fradured 
limb,  and  the  fradture  of  both  bones  when  there  are 
two,  as  well  as  fradures  accompanied  with  extenfive 
wounds  of  the  contiguous  foft  parts,  are  eafily  difcov- 
ered :  but  in  fimple  fractures,  where  only  one  bone 
of  a  limb  has  fuftered,  it  is  often  difficult  to  judge  with 
any  degree  of  precifion  ;  particularly  where  the  con- 
tiguous parts  have  become  tenfe  and  painful.  Infuch 
cafes,  our  opinion  muft  be  formed  by  a  minute  atten- 
tion to  different  circumftances  ;  the  age  and  habit  of 
body  of  the  patient  ;  the  fite  of  the  fuppofed  frafture  ; 
the  fituation  of  the  limb  when  the  injury  was  receiv- 
ed ;  and,  laftly,  the  attending  fymptoms. 

In  old  age,  bones  are  more  eafily  fra£lured  than  In 
earlier  periods  of  life.  In  infancy,  bones  will  rather 
yield  than  break  on  the  application  of  a  moderate  force ; 
whilfl  in  old  age  they  become  fo  brittle,  that  even  the 
largeft  are  frequently  broken  by  very  trifling  falls  and 
bruifes. 

Different  difcafes  induce  this  brittle  flate  of  the 
bones  ;  particularly  lues  venerea.  Of  this  I  have  met 
with  various  inflances.  In  fome  of  thefe,  the  largeft 
and  hardeft  bones  were  broken,  folely  by  the  ordina- 
ry adtion  of  the  mufcles  of  the  limb.  This  I  have  al- 
fo  known  happen  in  fea  fcurvy  :  bones  that  have  been 
fractured  and  long  united,  are  apt  to  feparatc  in  ad- 
vanced ftages  of  fcurvy,  the  callus  being  either  diffolv- 
ed  or  rendered  too  foft  for  the  purpofe  of  retaining 
them  together. 

Befides  thefe  general  difeafes  of  the  body,  the  bones 
themfelves  are  liable  to  a  diCeafe  that  renders  them  foft 
and  flexible.  This  is  u'uaily  termed  mollifies  oflium. 
In  fome,  this  goes  no  farther  than  to  produce  that  flate 
of  the  bones  that  I  have  mentioned,  in  which  they  are 


3i6  General  Obfervations       Chap.  XXXIX. 

apt  to  be  fractured  by  flight  falls  and  fimilar  accidents : 
but  in  others,  it  has  been  known  to  proceed  to  fuch  a 
height,  that  every  bone  in  the  body  has  become  crook- 
ed and  diftorted.  I  have  feen  a  fkeleton  in  which  the 
condyles  of  the  knee  joints  were  turned  up  fo  as  to 
touch  the  pubes,  and  in  which  every  other  bone  was 
crooked  in  nearly  a  fimilar  degree. 

In  judging  therefore  of  the  probability  of  a  fraclure 
from  the  degree  of  violence  that  has  been  applied,  thefe 
circumftances  merit  attention  :  for  it  is  evident,  that 
in  old  age,  and  in  thefe  difeafed  flates  of  bones,  a  de- 
gree of  force  will  produce  fradure,  which  in  other 
circumftances  it  could  not  poflibly  do. 

The  (ite  of  a  fuppofed  fra6lure  is  alfo  to  be  taken 
into  confideration.  Bones  are  more  apt  to  be  broken 
in  thofe  places  where  they  are  hard  and  brittle,  as  in 
the  firmer  parts  of  all  the  long  bones,  than  towards 
their  extremities,  where  they  are  of  a  more  foft  and 
yielding  texture ;  and  bones  that  he  deep  under  the 
cover  and  protection  of  mufcular  parts,  as  in  the  thighs, 
are  not  fo  frequently  fra6tured  as  thofe  of  the  arms 
and  legs  that  are  not  fo  w^ell  prote6led. 

Further,  the  fituation  of  a  limb  when  an  injury  is 
inflifted,  is  an  obje£t  of  inquiry.  Thus,  a  very  incon- 
fiderable  weight  pafling  over  a  bone  lying  on  an  une- 
qual furface,  will  readily  produce  a  fradure  ;  while 
the  fame  bone,  equally  fupported,  will  bear  a  heavy 
load  without  being  much  injured. 

In  forming  an  opinion  of  the  probability  of  a  bone 
being  broken,  we  ought,  laftly,  to  take  into  confider- 
ation the  fymptoms  that  ufually  accompany  fradtures. 
Thefe  are,  pain,  fweUing,  and  tenfion  in  the  contigu- 
ous parts ;  a  more  or  lefs  crooked  and  diftorted  ftate 
of  the  Hmb  ;  a  crackling  or  grating  noife  on  the  parts 
being  handled  ;  and  lofs  of  power  to  a  certain  degree 
in  the  injured  limb. 

It  is  true,  that  the  mere  fracture  of  a  bone  is  not 
neceflarily  attended  with  much  pain  ;  for  the  bones, 
not  being  fo  plentifully  fupplied  with  nerves  as  the 


\ 


Sect.  I.  on  FraSlures,  317 

fofter  parts  of  the  body,  they  are  therefore  of  a  lefs  ir- 
ritable nature.  But  pain  arifes  from  two  circumftan- 
ces  with  which  fraduies  are  ufually  attended  ;  the 
contiguous  foft  pa;ts  being  bruifed  and  otherwife  hurt, 
in  the  firft  place  by  the  force  producing  the  injury, 
and  afterwards  by  the  difplaced  ends  of  the  bones. 
For  the  mod  part  the  pain  indeed  is  not  very  fevere  : 
but  in  fomeit  is  fo  violent  as  to  induce  the  mod  alarm- 
ing fymptoms  ;  fpafmodic  twitchings  of  the  mufcles 
of  the  limb  ;  high  degrees  of  inflammation  ;  fever  ; 
general  convulfions  and  delirium  ;  and  if  the  caufe 
by  which  thefe  fymptoms  are  induced  be  not  foon  ob- 
viated, they  fometimes  even  terminate  in  death.  In 
general  this  is  preceded  by  mortification  of  the  parts 
contiguous  to  the  fradture ;  but  in  fome  thefe  fymp- 
toms prove  fatal,  without  any  tendency  to  gangrene 
being  perceived. 

When  the  force  by  which  a  frafture  is  produced 
has  been  extenfively  applied  over  a  limb,  we  may  read- 
ily fuppofc  that  the  fevereft  fymptoms  may  be  induced 
by  this  caufe  alone  ;  but  in  general  we  find,  when  the 
pain,  tenfion,  and  convulfive  twitchings  of  the  muf- 
cles are  fevere,  that  they  chiefly  arife  from  the  adjoin- 
ing membranes,  mufcles,  and  other  foft  parts  being 
torn,  punftured,  or  comprefied,  by  the  ends  of  the 
fractured  bones :  and  although  this  may  happen  in 
fraftures  of  every  defcription,  yet  it  will  neceflarily  be 
more  frequent  in  thofe  that  are  fo  oblique  as  to  admit 
of  the  bones  pafllng  eafily  over  each  other,  than  in 
tranfverfe  fractures,  where  the  parts,  on  being  replac- 
ed, more  readily  remain  in  their  natural  fituation. 

The  other  diagnoftic  fymptoms  of  fracture  that  I 
enumerated,  namely,  a  grating  noife  on  the  parts  be- 
ing handled,  and  difliortion  and  lofs  of  power  to  a  cer- 
tain degree  in  the  injured  limb,  muft  necefl'arily  take 
place  in  every  frafture.  They  are  indeed  much  more 
evident  in  fome  fra(^nrcs  than  in  others  ;  but  in  all, 
they  may  be  difcovered  where  the  parts  are  not  much 
fwellcd,  excepting  in  the  cafe  of  a  longitudinal  or  fplin- 


3i8  General  Obfcrvaiions       Chap.  XXXIX. 

tered  fradure.  A  bone  may  be  fpllt  in  this  direftion 
without  any  of  thel'e  fymptoms  taking  place  :  for  un- 
lefs  the  divided  parts  be  completely  feparated  from 
each  other,  neither  diftortion  nor  crackling  will  be 
perceived  on  handling  them  ;  nor  will  the  bone  be 
rendered  altogether  incapable  of  performing  its  ufual 
functions.  In  fuch  cafes,  we  judge  of  the  probability 
of  a  fracture,  from  the  violence  of  the  injury,  the  fe- 
verity  of  the  fymptoms,  and  other  circumflances  al- 
ready enumerated. 

Bcfides  thefe  leading  fymptoms  of  fractures  that 
take  place  immediately  on  the  injury  being  inflicted, 
there  are  others  which  occafionally  occur  from  the 
firft,  and  fome  that  we  are  to  confider  as  confequen- 
ces  rather  than  fymptoms.  Of  the  firft,  the  moll  re- 
markable are,  that  great  degree  of  ecchymofis  which 
in  fome  cafes  appears  inftantaneoufly,  from  the  ends 
of  a  fractured  bone  having  penetrated  a  contiguous 
artery  or  vein  ;  and  the  wound  or  laceration  of  the 
teguments  in  compound  fractures. 

The  moft  important  confequences  of  fra£tures  are, 
ftiffnefs  and  immobility  of  the  injured  limb  ;  diftortion 
of  the  parts  chiefly  affe6ted,  either  from  a  fulnefs  or 
thicknefs  remaining  in  the  contiguous  mufcles  or  lig- 
aments ;  an  exuberancy  of  callus  ;  a  contracted  ftate 
of  the  contiguous  joints  ;  or  a  marafmus  or  wafting 
of  the  limb  itfelf.  All  thefe  we  ftiall  confider  more 
particularly  in  fpeaking  of  the  treatment  of  fractures. 

In  judging  of  a  fracture,  and  of  the  probable  event 
of  it,  various  circumftances  are  to  be  confidered  :  par- 
ticularly the  age  and  habit  of  body  of  the  patient ;  the 
fituation  of  the  bone,  and  the  part  of  it  that  is  injur- 
ed ;  the  nature  of  the  attending  fymptoms  ;  the  cir- 
cumftances with  which  the  fracture  may  be  compli- 
cated ;  and  the  kind  of  fracture. 

With  refpeCt  to  the  firft  of  thefe,  namely,  the  age 
and  habit  of  body  of  the  patient,  wc  all  know  that 
they  are  points  of  much  importance  in  the  cure  of  ev- 
ery injury  ;  and  in  none  more  than  in  natures.  Thus 


Se£t.  I.  on  ¥ra6lures.  319 

in  youth,  particularly  in  infancy,  fradures  are  more 
quickly  cured  than  in  old  age  ;  and  in  found  confti- 
tutions,  more  readily  than  in  thofe  that  arc  difeafed. 
1  have  obferved  above,  that  the  bones  fometimes  be- 
come brittle  in  lues  venerea ;  and  it  may  here  be  re- 
marked, that  the  exiilence  of  lues  venerea  and  fcurvy, 
is  particularly  adverfe  to  the  reunion  of  fradlured  parts. 
I  have  met  with  foine  exceptions  to  this,  where  frac- 
tures have  urited  readily  even  in  advanced  ftages  of 
lues  venerea :  but  this  is  uncommon  ;.  and  where  lues 
venerea  has  attacked  the  bones,  a  firm  callus  feldoni 
forms  till  the  virus  is  eradicated. 

In  fpeaking  of  the  effe£l  of  age  on  the  cure  of  frac- 
tures, although  I  admit  that  the  divided  parts  of  bones 
unite  more  fpccdily  in  infancy  than  in  old  age,  yet  I 
think  it  right  to  remark,  that  they  do  not  reunite  with 
more  certainty.  By  many  we  are  told,  that  in  ad- 
vanced periods  of  life,  the  union  of  fraclured  bones 
is  often  not  to  be  accomplilhed.  I  have  never,  how- 
ever, feen  an  inftance  of  this,  although  I  have  had  the 
management  of  many  fractures  even  in  extreme  old 

The  fituation  and  part  of  the  injured  bone,  are  both 
circumftances  that  merit  attention.  Thus  we  know, 
that  fra£lures  of  the  fmall  bones  of  the  arms  and  legs, 
of  the  feet  and  hands,  and  of  the  ribs,  in  general  heal 
eafily  ;  while  fraftures  of  the  larger  bones,  particular- 
ly ot  the  femur  and  humerus,  are  managed  with  more 
difficulty.  In  the  lafl,  indeed,  one  principal  caufe  of 
the  cure  proving  tedious,  is  the  difficulty  of  retaining 
the  ends  of  the  bone  together. 

When  any  of  the  large  bones  are  fradured  near  to 
their  extremities,  we  find  the  danger  is  greater,  and 
the  profped  of  a  complete  cure  much  lefs,  than  when 
they  are  broken  near  to  their  middle :  for  here  the 
fhortnefs  of  one  end  of  the  bone  makes  the  retention 
difficult ;  and  the  fymptoms  that  enfue  from  fraclures 
m  this  fituation  are  apt  to  be  particularly  fevere,  not 
OTily  from  the  contiguity  of  the  capfular  ligaments  of 


320  General  Obfervatlons       Chap.  XXXIX. 

the  joints,  which  may  thus  be  injured,  but  from  the 
numerous  tendons  that  are  inierted  into  thefe  parts  of 
the  bones  j  which  may  not  only  be  lacerated  and 
bruifed,  but  even  torn  from  their  infertions.  Befides, 
the  ends  of  bones  are  not  only  foft,  but  even  fpongy 
or  cellular  in  their  texture,  by  which  fractures  in  thefe 
parts  do  not  unite  fo  equally  ;  the  parts  more  fre- 
quently exfoliate,  and  matter  is  more  apt  to  form  in 
them :  hence  when  fradured  they  are  more  tedious 
in  the  cure,  and  give  rife  to  more  troublefome  fymp- 
toms,  than  fnnilar  accidents  in  the  harder  parts  of 
bones. 

It  is  alfo  proper  to  remark,  that  fraftures  near  the 
extremities  of  bones  are  frequently  productive  of  ftift' 
immoveable  joints,  unwieldy  limbs,  pains  and  fwell- 
ings  ;  which,  in  various  inftances,  even  under  the  beft 
treatment,  continue  obftinate  for  a  great  length  of 
time,  and  in  fome  cafes  even  during  the  life  of  the  pa- 
tient. 

We  are  in  general  led  to  fuppofe,  that  thefe  confe- 
quences  arife  folely  from  mifmanagement,  either  on 
the  part  of  the  furgeon  or  of  the  patient.  That  in 
fome  inftances, this  is  the  cafe,  no  perfon  will  doubt. 
The  ends  of  a  fraftured  bone  may  be  improperly  plac- 
ed from  the  hrft  by  the  pratlitioner,  or  they  may  be 
afterwards  mifplaced  by  the  patient ;  and  in  either  cafe 
we  may  conceive  tliat  all  the  fpmptoms  I  have  men- 
tioned will  take  place.  But  in  juftice  to  the  profef- 
fion,  1  muft  obferve,  that  they  more  frequently  arife 
from  the  fituation  and  nature  of  the  fracture  than 
from  any  other  caufe.  l>Ior  is  it  furprifmg  that  it 
(hould  be  fo.  When  v/e  conlider  the  various  circum- 
ftances  with  which  fraftures  are  often  accompanied  ; 
the  degree  of  violence  required  to  break  a  large  bone  ; 
the  fe\  ire.  contufion  of  the  contiguous  foft  parts  which 
this  muft  produce  ;  and  the  laceration  of  nerves,  muf- 
cles,  and  ligaments,  that  muft  occur  from  the  fpiculje 
of  fradured  bones ;  we  fhould  rather  expect  that  th 


Seel.  I.  o'n  FraHuresi  321 

would  more  frequently  induce  diftrefsful  confequen- 
ces  than  we  aftually  find  to  be  the  cafe. 

In  forming  a  judgment  of  the  nature  and  probable 
event  of  fradures,  the  fymptoms  merit  particular  at- 
tention. If  the  fymptoms  are  moderate,  when  com- 
pared with  the  violence  that  the  parts  have  fuffered, 
our  prognofis  fhould  be  proportionally  favourable : 
but  when  the  attending  fymptoms  are  fevere,  particu- 
larly if  the  pain  is  uncommonly  violent,  and  the  fwell- 
ing  and  tenfion  confiderable,  however  trifling  the  force 
may  have  been  by  which  the  fracture  was  produced, 
the  cafe  will  probably  be  difficult  to  manage,  and  un- 
certain in  the  event.  In  fuch  circumftances,  there- 
fore, even  in  fimple  fradtures,  our  prognofis  fhould  be 
guarded. 

The  circum.flances  with  which  a  fradure  may  be 
complicated,  are  likewife  of  importance ;  and  unlefs 
they  are  duly  weighed,  no  accurate  judgment  can  be 
formed  of  the  event.  The  contiguous  mufcles  and 
other  foft  parts  may  be  feverely  contufed ;  fome  of 
the  ligaments  and  tendons  of  the  injured  part  may  be 
ruptured,  or  even  torn  from  their  infertions ;  and  the 
frafture  may  be  combined  with  a  diflocation  of  one 
or  both  of  the  contiguous  joints.  Thefe  accidents  in 
every  inftance  aggravate  the  danger. 

The  laft  confideration  on  this  fubjed  refpeds  the 
kind  of  fradure.  The  greateft  difference  is  obferved 
between  the  event  of  a  fmiple  and  of  a  compound 
fradure.  A  great  proportion  of  cafes  of  fimple  frac- 
ture are  of  a  mild  nature  from  the  firfl ;  and  with 
very  ordinary  attention,  complete  cures  are  obtained  : 
but  in  compound  fractures,  the  fmallefl  external 
wound  communicating  with  the  injury  in  the  bone, 
will  often  produce  the  greatefl  danger.  I  do  not  mean 
to  fay  that  this  always  happens  ;  on  the  contrary,  we 
know  that  even  the  worfl  cafes  of  compound  frailures 
will,  with  proper  attention,  often  terminate  in  a  fa- 
vourable manner :  but  every  practitioner  verfant  in 
this  branch  of  bufinefs,  will  allow,  that  this  is  feldom 

Vol.  III.  X 


32a  General  Obfervatms      Chap.  XXXlX^ 

the  cafe ;  and  that  even  under  the  befl:  management 
fuch  cafes  are  fo  apt  to  go  wrong,  as  to  warrant  the 
opinion  that  I  have  given  of  them,  and  to  render  it 
proper  in  ahnoft  every  inflance  to  give  a  guarded 
prognofis. 

Various  indications  have  been  propofed  for  the  cure 
of  fractures  ;  and  thofe  we  are  defired  to  have  partic- 
ularly in  view,  are,  extenfion ;  counter  extenfion ; 
coaptation,  or  replacement  of  the  fractured  parts  ;  de- 
ligation,  in  fo  far  as  is  neceflary  for  retaining  them  ^ 
pofition  of  the  injured  part  j  and  prevention  or  re- 
moval of  bad  fymptoms. 

The  fubjeft,  however,  may  be  fimplified,  and  the 
indications  with  propriety  reflricted  to  three :  to  re- 
place the  parts  of  the  bone  that  have  been  moved  from 
their  natural  fituation ;  to  retain  them  in  this  fitua- 
tion  as  long  as  may  be  neceflary  ;  and  to  obviate  fuch 
fymptoms  as  may  fupervene  during  the  cure. 

In  fome  few  favourable  cafes,  where  the  bones  are 
fraftured  directly  acrofs,  they  are  either  not  moved 
out  of  their  natural  fituation,  or  the  alteration  is  fo 
inconfiderable  that  they  are  eafily  replaced.  But  when 
the  bones  of  a  limb  are  broken  in  an  oblique  direction, 
they  are  apt  to  pafs  one  another  fo  as  to  produce  much 
deformity  and  pain.  The  contiguous  mufcles  are  thus 
feverely  injured,  and  excited  to  violent  adtion :  hence 
the  malady  is  increafed  by  every  exertion ;  and  noth- 
ing will  remove  it  but  an  artificial  replacement  of  the 
diftorted  bones. 

To  accomplifh  this,  various  methods  have  been  pro- 
pofed. In  former  times  it  was  done  by  much  violence 
and  force ;  by  what  was  termed  extenfion  and  counter 
extenfion :  but  we  now  know  that  our  purpofe  may 
be  accomplifhed  in  an  eafier  manner,  with  lefs  pain  to 
the  patient,  and  lefs  trouble  to  the  operator. 

As  long  as  it  was  imagined  that  much  force  was 
neceffary,  the  liinb  was  extended  by  one  or  more  af- 
fiitants  pulling  at  each  end  of  it  5  and  when  this  was 
not  fufficient,  diifferent  machines  were  employed  fof 


Sed.  I.  on  Fractures.  323 

it.  This  force  was  in  general  applied  while  the  limb 
was  ftretched  out  or  extended,  by  which  it  became 
much  more  difficult  to  reduce  the  difplaced  ends  of 
the  bone :  for  in  this  manner  all  the  contiguous  muf- 
cles  were  put  into  a£lion  ;  nor  could  the  bones  be  re- 
placed till  this  was  overcome  by  the  application  of  a 
fuperior  force.  The  mifchief  that  this  would  often 
produce,  it  is  eafier  to  imagine  than  exprefs. 

When  it  is  confidered,  that  in  the  reduction  of  frac- 
tured bones,  the  chief  refiflance  arifes  from  the  action 
of  the  correfponding  mufcles,  the  propriety  of  placing 
the  limb  in  fuch  a  pofture  during  the  operation,  as 
may  favour  the  relaxation  of  thefe  mufcles,  is  fo  evi- 
dent, that  we  now  refled  with  furprife,  that  it  fhould 
have  been  left  to  the  practitioners  of  the  prefent  age 
to  propofe  it.  For,  whatever  may  have  been  the  opi- 
nion of  a  few,  it  is  certain,  that  till  lately  it  was  the 
general  practice  to  keep  every  limb  in  an  extended 
pofition  while  any  attempt  was  making  to  replace  the 
fradured  bones,  and  that  it  is  chiefly  to  the  late  Mr. 
Pott  we  owe  the  prefent  improved  ftate  of  this  impor- 
tant branch  of  chirurgical  pradice. 

If  in  the  treatment  of  fractures,  we  take  care  to  re- 
lax all  the  mufcles  of  the  limb,  it  is  furprifmg  with 
what  eafe  the  ends  of  the  bones  may  in  general  be  re- 
placed. When  a  limb  is  laid  completely  in  this  re- 
laxed poflure,  the  furgeon  will  in  mod  cafes  be  able 
to  replace  the  bones  without  any  alliftance  :  but  whea 
this  does  not  fucceed,  a  flight  degree  of  extenfion  may 
be  employed,  by  the  upper. part  of  the  hmb  being 
kept  firm  by  one  afllfl:ant  with  his  hands  placed  be- 
tween the  fradture  and  the  contiguous  joint,  while  the 
under  part  of  it  is  gently  extended  by  another  ;  care 
being  fliill  taken,  however,  to  keep  the  mufcles  as 
much  relaxed  as  poflible. 

As  it  is  of  much  importance,  in  replacing  the  frac- 
tured parts  of  a  bone,  to  do  it  with  accuracy,  the  moft: 
minute  attention  fliould  be  given  to  this  part  of  the 
operation.  Every  inequality  depending  upon  any  por- 
X  2 


324  General  Ohfcrvatiom       Chap.  XXXIX# 

tion  of  a  difplaced  bone,  fhould,  as  much  as  poffible, 
be  removed,  fo  as  to  render  the  injured  part  fimilar 
to  the  correfponding  found  limb  ;  which,  for  the  pur- 
pofe  of  a  more  attentive  examination,  ihould  be  plac- 
ed as  near  to  it  as  the  conveniency  of  the  operator 
will  permit. 

The  neceflity  of  attention  to  this  part  of  the  treat- 
ment will  particularly  appear  from  this,  that  when  the 
fraclured  bones  are  not  properly  reduced  at  firft,  the 
limb  mufl  either  remain  always  diftorted,  or  be  put 
right  during  a  future  flage  of  the  cure,  when  it  will 
necelTarily  be  done  with  more  pain  to  the  patient,  and 
more  trouble  and  perplexity  to  the  furgeon. 

The  bones  being  put  right,  our  next  obje£l  is  to  re- 
tain them  as  long  as  may  be  neceifary  in  this  fituation. 
This  we  do  with  fpllnts  and  bandages,  and  placing  the 
limb  in  fuch  a  ftate  of  relaxation  as  will  admit  of  its 
refting  with  eafe,  and  without  being  diflurbed,  till  the 
cure  is  completed.  In  treating  of  fradtures  of  parti- 
cular bones,  the  pofture  in  which  they  fhould  be  pla- 
ced, and  the  bandages  beft  adapted  for  their  retention, 
will  be  defcribed.  I  may  merely  obferve  at  prefent, 
that  no  bandage  fhould  be  more  tightly  applied  than 
merely  to  retain  the  bones  in  their  fituation  ;  and  that 
this  may,  for  the  mofl  part,  be  eafily  done,  if  the  limb 
is  kept  in  a  relaxed  pollure. 

The  time  required  for  the  firm  reunion  of  fractur- 
ed bones  depends  upon  various  circumftances :  upon 
the  fize  of  the  bone,  and  the  weight  that  it  has  to 
fupport ;  on  the  age  and  habit  of  body  of  the  pa- 
tient ;  and  on  the  cure  having  proceeded  with  more 
or  lefs  interruption,  from  the  limb  having  been  kept 
more  or  lefs  fleadily  in  its  fituation,  as  well  as  from 
the  attending  fymptoms  of  fweiling,  pain,  and  inflam- 
mation, having  been  mild  or  fevere.  In  a  healthy 
middle  aged  patient,  where  no  untoward  fymptoms 
have  occurred,  and  when  the  injured  parts  have  been 
retained  exactly  in  their  fituation,  a  cure  of  a  fractur- 
ed femur,  or  of  the  bones  of  the  leg,  will  be  accom- 


Sed:.  I.  on  FraSiurcs.  325 

plifhed  in  two  months ;  of  the  humerus  and  bones  of 
the  fore-arm,  in  fix  weeks  ;  of  the  clavicles,  ribs  and 
bones  of  the  fingers  and  toes,  hands  and  feet,  in  three 
weeks.  In  infancy  and  childhood,  fraftures  in  all 
thefe  parts  heal  more  quickly,  while  in  old  age  this 
uniting  proccfs  goes  on  more  flowly,  and  therefore 
requires  more  time  to  accomplifh. 

In  fimple  fradures,  to  which  thefe  general  obferva- 
tions  more  particularly  apply,  the  pain,  tenfion,  and 
other  fymptoms,  are  in  general  moderate,  and  ufually 
fubfide  entirely  in  the  courfe  of  a  few  days,  if  the 
bones  are  properly  retained  in  their  fituation  ;  but  in 
fome  cafes,  inflead  of  diminidiing,  they  become  daily 
more  violent,  fo  as  to  be  produftive  of  much  diftrefs 
to  the  patient,  as  well  as  trouble  and  embarraflment 
to  the  praftitioner. 

When  the  mufclcs  and  other  foft  parts  of  the  limb 
have  not  been  much  contufed,  no  remedy  fhould  be 
advifed  merely  with  a  view  to  the  prevention  either 
of  tenfion  or  pain  :  but  when  much  violence  has  been 
done  to  the  limb,  thefe  fymptoms  fhould  be  guarded 
againfl  by  the  early  ufe  of  allringent  applications,  fuch 
as  folutions  of  faccharum  faturni,  of  crude  fal  ammo- 
niac, and  fpiritus  Mindereri ;  and  when  thefe  fail,  by 
a  free  appHcation  of  leeches  over  the  injured  parts. 
Indeed,  the  prad:ice  of  taking  away  blood  by  leeches 
proves  in  every  inflance  fo  highly  ufeful,  that  I  always 
advife  it  when  the  tenfion  is  confiderable,  or  whenever 
the  pain  continues  fevere  after  the  bones  have  been 
replaced.  In  every  frafture,  inflammation  is  the 
fymptom  which,  in  the  firft  place,  we  have  moft  rea- 
fon  to  dread  ;  and  as  nothing  tends  with  fuch  cer- 
tainty to  prevent  or  remove  it  as  local  bloodletting,  it 
fhould  never  be  omitted  at  firft  when  the  furrounding 
foft  parts  are  much  injured  :  nor  fliould  it  aftei*wards  be 
delayed  when  it  appears  to  be  neceflary  ;  for  this  reme- 
dy proves  always  moft  efte£i:ual  when  employed  early. 

Befides  the  mimediate  advantage  of  relieving  the 
pain  in  the  injured  part,  nothing  prevents  with  fuch 


326  General  Obfervations       Chap.  XXXIX. 

certainty  the  troublefome  confequences  of  contufion 
in  cafes  of  fraclure,  as  the  early  application  of  leeches. 
Of  thefe  confequences,  the  mofl  remarkable  are,  deep 
feated  abfcelfes,  which  in  fome  inflances  form  within 
the  cavity  of  the  bone  itfelf,  and  in  others  in  the  fur^ 
rounding  cellular  fubftance  ;  long  continued  pains,  re- 
fembling  rheumatifm,  ftretching  over  the  injured  limb; 
a  thickened  enlarged  ftate  of  the  periofteum  and  oth- 
er foft  parts ;  a  fhifF  contrafted  ftate  of  the  contigUf 
ous  tendons  ;  an  exuberancy  of  callus  j  and  an  un- 
wieldy ilate  of  the  whole  member. 

It  is  well  known  to  every  furgeon  of  experience, 
that  all  of  thefe  confequences  are  apt  to  fucceed  to 
fractures  accompanied  with  much  contufion ;  and  no- 
thing proves  more  perplexing  to  furgeons,  or  more  dif- 
trefsful  to  patients  ;  for  when  they  are  not  foon  remo- 
ved, they  are  very  apt  to  prove  permanent ;  and  for 
the  moll  part  this  is  laid  to  the  charge  of  mifmanage- 
ment  in  the  reduction  of  the  fracture. 

In  many  inftances  thefe  confequences  no  doubt  pro- 
ceed from  the  extremities  of  the  fradtured  bone  not 
being  properly  replaced,  or  not  retained  with  exaft- 
nefs  afterwards  :  but  they  more  frequently  proceed 
from  the  inflammation  that  fucceeds  to  contufion.  It  is 
therefore  evident,  that  early  local  bloodletting  is  in  fuch 
circumftances  moil  likely  to  prove  ufeful.  When 
fwelling  and  pain  in  a  fractured  limb  have  continued 
long,  the  mod  effectual  relief  is  obtained  from  fric- 
tions with  emollient  oils,  and  from  tepid  bathing  in 
warm  fea  water,  and  in  the  waters  of  Buxton,  Bath,  and 
Barreges.  But  in  the  early  ftages  of  fra£lures,  nothing 
removes  the  pain  with  fuch  certainty  as  a  plentiful  dif- 
charge  of  blood  froui  the  injured  parts. 

We  are  fometimes  difappointed  in  the  cure  of  frac- 
tures, by  the  limbs  remaining  unfeemly  from  an  over- 
growth of  callus.  This  is  not  indeed  a  frequent  oc- 
currence, but  every  practitioner  mufl  have  met  with 
it :  being  mod  apt  to  take  place  where  the  fymptoms 
of  inflammation  have  been  fevere,  I  have  regularly  or- 


Sedi.  I.  en  Fradures.  "^if 

dered  local  bloodletting,  for  the  prevention  and  remo- 
val of  this  exuberancy  of  callus,  and  commonly  with 
much  advantage  ;  but,  in  fome  cafes,  the  tendency  to 
form  callus  is  fo  great,  that  it  can  fcarcely  be  check- 
ed. The  application  of  ardent  fpirits,  and  other  af- 
tringents,  is  here  fuppofed  to  prove  ufeful :  and  I  have 
in  fome  inftances  derived  advantage  from  continued 
gentle  preflure,  applied  by  means  of  a  thin  plate  of 
lead  adapted  to  the  form  of  the  part,  and  retained  with 
a  proper  bandage  :  but  as  neither  this  nor  any  other 
remedy  ■will  prove  fuccefsful  in  every  cafe,  and  as  pa- 
tients are  apt  to  regret  nothing  fo  much  as  difappoint- 
ment  in  obtaining  a  complete  cure  of  a  fracture,  our 
fafeft  courfe,  as  Toon  as  the  callus  begins  to  be  luxu- 
riant, is  to  acquaint  the  patient  with  the  probable 
event ;  and  he  muft  be  very  unreafonable  indeed,  if 
he  afterwards  repines  at  what  the  utmoft  care  and  at- 
tention could  not  prevent. 

Among  the  confequences  that  fometimcs  refult  from 
fradlures,  there  is  one  that  merits  more  particular  con- 
fideration,  namely,  the  difficulty  of  obtaining  an  union 
between  the  ends  of  the  fradlured  bones,  by  which 
they  remain  loofe  and  detached  long  after  they  (hould 
have  been  firmly  united. 

This  may  proceed  from  various  caufes :  from  con- 
ftitutional  difeafes,  fuch  as  rickets,  fcurvy,  or  lues  ve- 
nerea ;  from  the  ends  of  the  fractured  bones  not  be- 
ing kept  fleadily  in  contact  till  completely  united  ; 
from  a  portion  of  a  mufcle,  tendon,  or  ligament,  fall- 
ing between  the  ends  of  the  fradured  parts,  fo  as  to 
prevent  them  from  being  placed  in  contact ;  and  in 
fome,  from  a  bone  being  broken  in  different  parts,  and 
the  intermediate  detached  pieces  being  fo  fmall  as  to 
prevent  them  from  adhering,  even  when  kept  in  clofe 
contad. 

It  has  been  obferved,  too,  that  a  ftate  of  pregnancy 
proves  inimical  to  the  recovery  of  fradtured  bones. 
This  has  not  indeed  fallen  within  my  obfervation  ;  but 
it  appears  to  be  the  general  opinion  of  pradlitioners, 
and  different  inllances  of  It  are  upon  record. 


328  General  Obfervatiom       Chap.  XXXIX, 

When  this  want  of  union  proceeds  from  any  gen^ 
eral  difeafe  cl  the  fyfliem,  this  difeale  mull  be  remov- 
ed by  the  remedies  that  experience  has  (hewn  to  prove 
mofl  effectual  ;  for  no  atterition  on  the  part  of  the 
furgeon  will  be  of  any  avail  till  this  is  accompli flied  ; 
and  as  much  m.iichief  is  often  prevented  by  an  early 
application  of  remedies,  they  fliould  always  be  advifed 
as  foon  as  the  caufe  is  found  to  exift.  It  would  even 
be  a  prudent  precaution,  where  a  patient  at  the  time 
of  receiving  a  fradlure  is  known  to  labour  under  any 
conflitutional  difeafe,  to  advife  an  immediate  applica- 
tion of  remedies  ;  by  which  means  cures  might  be 
often  quickly  accomplifhed,  which  otherwife  are  pro- 
tracted to  a  great  length. 

When  a  cure  is  interrupted  by  the  fra£lured  ends 
of  bones  not  being  kept  in  their  fituation,  they  fliould 
be  replaced  and  retained  with  as  much  accuracy  as 
pofTible  ;  and  when  the  injury  is  flill  recent,  often,  in- 
deed, for  the  fpace  of  two  or  three  weeks,  a  perfect 
union  may  thus  be  accompliilied. 

But  where  fractured  bones  have  remained  for  any 
confiderable  length  of  time  difunited,  the  oiTeous  mat- 
ter by  which  they  lliould  have  been  knit  together  be- 
comes hard,  fmooth,  and  totally  unfit  for  the  purpofe, 
infomuch  that  no  advantage  could  be  derived  from 
their  being  replaced.  Of  this  I  have  met  with  vari- 
ous inftances,  where  the  ends  of  the  fradured  bones 
were  become  perfectly  fmooth,  and  moved  on  each 
other  with  nearly  the  fame  eafe  and  freedom  as  the 
bones  of  any  of  the  joints. 

In  this  fituation,  when  the  inconvenience  which  it 
excites  is  inconfiderable,  the  patient  flioukl  be  advifed 
to  fubmit  to  it,  particularly  in  fractures  of  the  fmall 
bones,  fuch  as  thofe  of  the  fingers  and  toes,  the  bones 
of  the  metacarpus  and  metatarius,  the  clavicles,  and 
ribs,  rather  than  to  any  operation  for  effecting  a  cure  ; 
but  in  the  large  bones  of  the  extremities,  where  much 
firmnefs  is  required,  and  where  this  kind  of  injury  de- 
flroys  the  ufe  of  the  limb,  as  we  may  be  able  by  an 


Seel:.  I.  on  FraBures,  329 

operation  to  reftore  it,  we  ought  perhaps  in  every  in- 
ftance  to  propofe  it.  By  making  an  incifion  through 
the  furrounding  foft  parts,  fo  as  to  lay  the  ends  of  the 
bones  bare,  and  removing  a  fmall  portion  of  each  of 
them,  either  with  a  common  faw,  or  with  the  head  of 
a  trepan,  we  reduce  them  to  the  Itate  of  a  recent  frac- 
ture ;  when,  by  taking  care  to  retain  them  in  a  pro- 
per fituation,  we  may  in  due  time  accomphfh  a  cure. 

The  operation  is  no  doubt  painful  and  tedious  ;  for 
the  incifion  muft  be  extenfive,  in  order  to  admit  of  a 
free  application  of  the  inftruments  ;  and  it  requires  to 
be  conduded  with  caution,  that  the  large  blood  veflels 
of  the  limb  may  be  avoided  :  but  it  may  be  done  with 
perfedl  fafety  by  any  perfon  accuftomed  to  the  opera- 
tive part  of  furgery.* 

Nor  fhould  we  be  deterred  from  propofing  this 
method  of  cure,  from  any  apprehenfion  about  the  va- 
cancy that  may  be  produced  by  the  removal  of  the 
ends  of  the  bones  :  for  if  the  limb  is  kept  lleadily  in 
its  fituation,  and  if  the  conftitution  is  healthy,  nature 
will  not  probably  fail  in  fupplying  the  deficiency. 
Thus,  many  indances  are  upon  record,  even  of  entire 
bones  being  regenerated  ;  and,  in  a  lefler  degree,  the 
powers  of  nature  on  this  point  muft  have  fallen  with- 
in the  obfervation  of  every  praditioncr. 

A  bone  is  often  broken  in  different  parts,  and  a 
cure  notwithftandinci:  obtained  :  but  when  the  detach- 
ed  parts  are  fo  fmall  that  the  circulation  will  not  pro- 
bably be  kept  up  in  them,  as  they  will  thus  be  ren- 
dered incapable  of  furnilTiing  the  fccretion  by  which 
their  reunion  fliould  be  accompliflied,  it  would  be  bet- 
ter to  remove  them  at  once,  than  to  impede  the  cure 
by  any  attempt  to  fave  them.  Accordingly,  in  all 
compound  fradurcs,  where  the  injured  bone  is  already 
laid  bare,  it  is  the  beft  pradice  to  remove  all  fuch  de- 
tached portions  as  might  not  probably  unite  with  the 
icmaining  parts  of  the  bone.     But  in  funple  fractures, 

Vide  While's  Cafes  in  Surgery,  where  two  inflances  of  tliis  arc  rcr 
ccrdcd. 


330  General  Ohfervatlons       Chap.  XXXIX. 

where  the  fkin  remains  entire,  as  we  cannot  judge 
with  fuch  certainty  of  the  nature  and  extent  of  the  in- 
jury, nor  of  the  probability  of  our  being  able  to  pre- 
ferve  the  loofe  portions  of  bone,  we  fhould  endeavour, 
in  the  firft  place,  to  accomplifh  a  cure  in  the  eafieft 
manner,  by  placing  the  parts  in  fuch  a  pofition  as  will 
moft  readily  admit  of  their  reunion  :  but  when  this 
does  not  fucceed,  when  the  ends  of  the  bone  remain 
loofe  long  after  they  fliould  have  been  united,  and  if 
one  or  more  detached  pieces  are  difcovered,  thefe  are 
to  be  confidercd  as  extraneous  bodies,  and  ought  ac- 
cordingly to  be  removed,  either  with  the  fingers  or 
forceps,  at  an  opening  made  through  the  foft  parts  for 
this  purpofe. 

Experience  enables  me  to  recommend  this  pradice 
with  confidence.  I  have  met  with  various  cafes  in 
which  cures  were  judged  to  be  imprafticable,  from  no 
union  being  formed  between  the  ends  of  bones  that 
had  been  long  fradured,  and  in  which  I  proved  fuc- 
cefsful  at  laft,  by  the  removal  of  fome  loofe  fragments. 

But  the  moft  perplexing  caufe  of  failure,  in  the 
treatment  of  fractured  bones,  is  a  portion  of  a  mufcle, 
ligament,  or  fome  other  foft  part  pailing  between  them. 
We  judge  that  this  is  the  cafe,  when  the  pain  and  ten- 
fion  of  the  injured  part  have  been  more  fevere  than 
ufual  from  the  firil ;  when  particular  movements  of 
the  limb  occafion  fevere  pain  and  twitchings  of  the 
mufcles  that  ferve  to  move  it ;  and  vi^hen  the  ends  of 
the  fradured  bone  do  not  unite  at  the  ufual  time. 

As  foon  as  there  is  reafon  to  think  that  the  cure  is 
prevented  by  this  caufe,  we  fhould  endeavour  to  re- 
move the  portion  of  interpofing  membrane  or  mufcle, 
by  putting  the  limb  into  every  variety  of  pofture.  But 
when  this  does  not  fucceed,  as  may  fometimes  be  the 
cafe,  and  when  the  bones  ftill  remain  loofe  long  after 
the  ufual  period,  we  ought,  without  further  hefitation, 
to  make  an  incifion  upon  the  fradured  part.  When 
the  injury  has  not  been  of  long  duration,  a  cure  will 
be  accomplifhed  merely  by  bringing  the  ends  of  the 


Se£t.  I.  on  FraSlures.  331 

fraftured  bone  Into  contaft  ;  but  when  this  meafure 
has  been  long  delayed,  and  when  the  offeous  matter 
poured  out  by  the  fractured  extremities  of  the  bone 
has  become  hard,  a  fmall  part  of  it  fhould  be  remov- 
ed either  with  a  faw  or  fome  fharp  inflrument,  fo  as 
to  convert  the  injury  once  more  into  the  ft  ate  of  a  re- 
cent fradure  ;  otherwife  jio  advantage  will  be  gained 
by  the  operation. 

Befides  thefe  caufes  that  I  have  mentioned,  which 
tend  to  impede  the  cure  of  fractures,  it  may  not  be 
improper  to  remark,  that  the  eft'ufion  of  much  blood 
round  the  injured  bone,  is  v^ry  apt  to  do  harm.  In 
cafes  of  fimple  fracture,  the  larger  blood  veflels  are 
feldom  injured  ;  and  blood  effufed  from  fmall  arteries 
is  for  the  moft  part  foon  abforbed,  and  no  bad  confe- 
quences  enfue  from  it.  But  inftances  fometimes  oc- 
cur, even  in  fimple  fraftures,  of  large  blood  veflels 
being  cut  by  the  fliarp  fpiculse  of  the  bone.  When 
the  quantity  of  blood  thrown  out  is  confiderable,  the 
tumefadion  of  the  limb  becomes  fo  great,  that  it  is 
neceflary  to  lay  it  open  in  order  to  fecure  the  injured 
veflel  with  a  ligature  :  but  where  the  fwelling  does  not 
arrive  at  any  alarming  height,  we  rather  truft  to  the 
natural  contractility  of  the  artery,  for  ftopping  the 
hemorrhagy,  and  to  the  powers  of  the  abforbents,  for 
removing  the  blood  already  eft'ufed.  In  fome  fuch 
cafes,  where  blood  has  remained  long  in  contadl  with 
a  fra£lured  bone,  the  power  of  forming  callus  appears 
to  have  been  deftroyed  by  it ;  the  periofteum  feparates 
for  a  confiderable  ^pace  from  each  end  of  the  bone  ; 
and  on  laying  the  parts  open,  no  union  is  found  to 
have  taken  place  ;  the  fpiculee  produced  by  the  frac- 
ture remain  equally  (harp  as  at  firft  ;  and,  for  the  mofl: 
part,  a  thin  fetid  fanies  is  difcharged  from  the  fore. 

In  this  fituation,  a  cure  will  not  be  obtained  till 
thofe  parts  of  the  bone  which  have  been  denuded  of 
the  periofteum  have  exfoliated  ;  and,  as  exfoliation  is 
in  general  a  tedious  procefs,  I  would  rather  advife  the 
removal  of  the  denuded  bone  with  a  faw  j  by  which 


332  Of  Fraaures  of  the       Chap.  XXXIX. 

a  more  expeditious  and  more  certain  cure  would  be 
obtained. 

Having  premifed  thefe  general  obfervations,  we  pro- 
ceed to  the  confideration  of  fractures  of  particular 
bones. 


SECTION     II. 

Of  Fradures  of  the  Nofe, 

THE  arch  formed  by  the  bones  of  the  nofe,  pre- 
vents them  from  being  fo  frequently  fractured 
as  they  otherwife  would  be.  They  are  neceffarily, 
however,  liable  to  every  variety  of  fratture  when  ex- 
pofed  to  much  violence. 

Befidcs  the  ufual  fymptoms  of  fra£lures,  injuries  of 
this  kind  in  the  bones  of  the  nofe  are  apt  to  impede 
refpiration  ;  they  hurt  the  fpeech  and  fenfe  of  fmell- 
ing  ;  polypi  and  tedious  ulcers  fometimes  enfue  from 
them  ;  and  they  are  more  hazardous  than  fraftures  of 
other  bones,  from  their  contiguity  to  the  brain.  Thefe 
fraftures,  therefore,  require  very  accurate  attention. 

When  we  have  afcertained  the  nat-ure  and  extent 
of  the  fradure,  our  next  objeft  is  to  replace,  with  as 
much  accuracy  as  poffible,  fuch  parts  of  the  bones  as 
are  difplaced.  When  any  part  of  them  has  been  raif- 
ed  above  the  level  of  the  reft,  it  muft  be  prefled  into 
its  fituation  with  the  fingers  ;  while  fuch  parts  of  them 
as  may  have  been  forced  into  eitb-^r  of  the  noftrils, 
muft  be  elevated  with  the  end  of  a  narrow  fpatula,  or 
any  other  inftrument  of  a  fmiilar  form.  Any  portion 
of  bone  that  is  quite  loofe,  and  nearly  feparated  from 
the  reft,  fliould  be  removed  immediately,  whether  it 
be  raifed  up  or  forced  into  the  noftril  ;  but  whatever 
adhei-es  firmly  to  the  remaining  portion  of  bone  fliould 
be  replaced. 

If  the  bones  are  properly  replaced,  they  will  for  the 
moft  part  remain  in  their  fituation  without  aftiftance. 


Sed.  III.  Bones  of  the  Face,  333 

If  the  foft  parts  have  been  injured,  they  mufl:  bedrefT- 
ed  in  th6  ufual  way ;  and  whether  they  are  hurt  or 
not,  we  jfhould  endeavour  to  prevent  inflammation  by 
the  ufe  of  faturnine  applications,  and  by  local  blood- 
letting when  the  violence  of  fymptoms  feems  to  re- 
quire it. 

But  when  the  parts  that  have  been  replaced  do  not 
remain  firm  in  their  fituation,  fomething  mufl  be  done 
to  retain  them.  If  they  fall  into  the  noftrils,  we  fuc- 
ceed  beft  by  the  introduftion  of  tubes  of  fuch  a  fize 
into  them,  as  may  preferve  the  fraftured  bones  in  their 
fituation.  The  form  and  fize  of  thefe  tubes  are  delin- 
eated in  Plate  XXVI.  fig.  2.  If  the  tubes  are  cover- 
ed with  foft  lint,  fpread  with  any  emollient  ointment, 
they  may  be  kept  in  the  noftrils  as  long  as  is  neceifa- 
ry  :  while,  on  the  contrary,  if  any  part  of  the  bone  is 
raifed  above  the  reft,  it  muft  be  kept  down  by  a  pro- 
per application  of  a  double  headed  roller.  If  the  teg- 
uments are  injured,  the  fore  muft  be  firft  dreflTed  ;  care 
being  taken  in  doing  it  to  prevent  deformity  as  much 
as  pofTible  :  a  comprefs  of  foft  old  linen  muft  be  next 
applied  ;  and  over  the  whole  an  equal  preflure  with 
the  bandage  I  have  juft  mentioned. 

In  this  manner  a  cure  may  be  obtained  of  almoft 
every  injury  of  this  part,  unJefs  the  bones  have  been 
fo  much  fliattered,  that  their  reunion  cannot  be  accom- 
pliftied  :  in  which  event,  all  that  art  can  do  is  to  ex- 
trad  the  detached  pieces,  and  to  co-operate  as  much 
as  polTible  with  nature  in  healing  the  remaining  fore. 


SECTION     III. 
Of  rradurcs  of  the  Bones  of  the  Face.       • 

WHEN  treating  of  fradures  of  the  fkull,  in 
Chapter  X.  thofe  of  the  upper  part  of  the 
face  were  confidered.  At  prefent,  therefore,  I  have 
©nly  a  few  obfervations  to  oficr  on  fradures  of  the  fu- 


334  Of  Fraaures  of  the      Chap.  XXXIX. 

perior  maxillary  and  cheek  bones,  being  thofe  which 
form  the  moft  prominent  parts  of  the  fides  of  the  face. 

The  vicinity  of  thofe  bones  to  the  eyes  and  nofe, 
and  the  fituation  of  the  antrum  maxillare,  make  frac- 
tures in  this  part  highly  important.  When  fradures 
ftretch  toward  the  eyes,  they  are  apt  to  induce  fevere 
degrees  of  inflammation  ;  and  when  they  penetrate  the 
antrum,  they  not  only  prove  tedious,  but  commonly 
occafion  much  deformity  :  for  when  the  anterior  part 
of  that  cavity  is  laid  open,  and  any  portion  of  the  bone 
removed,  the  face  becomes  flat,  and  the  teguments 
puckered,  notwithfl:anding  all  that  can  be  done  to  pre- 
vent it. 

In  all  fuch  injuries,  therefore,  we  fhould  with  the 
greatefl:  care  replace  any  portion  of  bone  that  may  be 
fraftured,  fo  as  to  favour  its  reunion  with  the  refl:  ;■ 
and  any  wound  that  accompanies  the  frafture,  fhould 
be  dreiled  with  much  attention,  that  deformity,  as  far 
as  poflible,  may  be  prevented. 

After  the  bones  are  replaced,  which  may  be  done 
with  the  fingers  where  there  is  no  wound,  and  with 
forceps  or  a  narrow  fpatula  when  the  parts  are  laid 
open,  a  piece  of  adhefive  plafl:er  will  anfwer  better 
than  any  bandage  for  retaining  the  drefllngs.  Blood- 
letting, and  an  antiphlogiftic  regimen,  mud  be  advif- 
ed  to  obviate  inflammation  of  the  eye  or  contiguous 
parts,  which  otherwife  might  enfue.  The  remaining 
part  of  the  cure,  namely,  the  reunion  of  the  fractured 
parts  of  the  bone,  mufl  be  left  to  nature. 

When  a  frafture  penetrates  the  antrum  maxillare, 
the  matter  which  collefts  in  that  cavity  cannot  be  pro^ 
perly  evacuated  from  any  opening  that  may  take  place 
on  the  prominent  part  of  the  cheek.  In  confequence 
of  this,  I  have  known  fmuous  ulcers  formed  that  have 
conthmed  open  for  a  great  number  of  years.  They 
can  only  be  healed  by  giving  a  free  vent  to  the  mat- 
ter, by  an  opening  made  in  the  moft  depending  part 
of  the  cavity,  in  the  manner  I  have  advifcd  in  Chap. 
XIV.  Sea.  V. 


Sed.  IV.  inferior  Maxillary  Bcnes.  335 

SECTION    IV. 

Of  Fradures  of  the  inferior  Maxillary  Bones, 

ALTHOUGH  the  bones  of  the  under  jaws  are 
very  ftrong  and  compadt,  yet  fractures  of  one, 
or  even  of  both,  are  not  unfrequent.  This  feems  to 
arife  from  blows  and  other  injuries  to  which  thefe 
bones  are  expofed,  being  moft  apt  to  fall  upon  their 
anterior  flat  furfaces,  where  they  are  lefs  capable  of 
refifting  violence  than  in  any  other  part.. 

"We  judge  of  the  e.xiftence  of  a  fradure  in  the  jaw, 
by  the  deformity  that  it  occafions  ;  by  the  crackling 
of  the  bone  when  handled  ;  by  inability  to  move  the 
jaw  ;  by  the  violence  of  the  injury,  and  degree  of  pain 
with  which  it  is  accompanied.  When  both  jaws  are 
broken,  the  injury  becomes  obvious  ;  as  in  this  cafe  a 
confiderable  feparation  takes  place  at  the  fradlured 
part :  but  even  where  one  bone  only  is  fradured,  it 
may  always  with  due  attention  be  difcovered. 

The  fite  of  the  fraclure  being  afcertained,  our  next 
objeft  is  to  replace  the  bones  with  as  much  care  as 
poUible :  this  we  do  by  placing  the  patient  in  a  pro- 
per light,  having  his  head  firmly  fecured,  and  the  fin- 
gers of  one  hand  prefTmg  upon  the  infide  of  the  jaw, 
while  the  other  hand  is  employed  externally  in  remov- 
ing any  perceptible  inequality  of  the  bone.  One  of 
the  teeth  is  commonly  feated  in  the  courfe  of  the  frac- 
ture ;  and  in  this  fituation  acting  as  an  extraneous 
body,  and  thus  tending  to  retard  the  cure,  it  fliould 
be  a  general  rule  to  take  it  out  immediately :  but 
\vhen  any  of  the  teeth  not  feated  in  the  courfe  of  the 
fradlure,  are' forced  out  of  their  fockets,  it  maybe 
right  almofl:  in  every  inftance  to  replace  them,  and  to 
endeavour  to  fix  them,  by  tying  them  to  the  contigu- 
ous firm  teethi 


■  1 

336  Of  Fraaures  of  the       Chap.  XXXIX. 

This  being  done,  our  next  object  is  to  retain  the 
fraftured  bones  in  their  fituation  till  they  are  firmly 
reunited.  For  this  purpofe,  a  variety  of  fplints  have 
been  invented,  both  of  paftcboard  and  other  materials  ; 
but  as  a  comprefs  and  bandage,  either  of  foft  old  linen 
or  cotton,  anfwers  the  purpofe  with  equal  certainty, 
and  as  it  fits  with  much  more  eafe  to  the  patient,  it 
fhould  always  be  preferred.  The  parts  being  kept 
firm  by  an  afliftant,  a  thick  comprefs  fliould  be  laid 
over  the  chin,  and  be  made  to  extend  from  ear  to  ear 
along  each  jaw ;  and  over  the  whole  a  four  headed 
roller  fhould  be  applied  in  the  manner  I  (hall  mention 
when  treating  of  bandages.  In  ufing  this  bandage,  it 
fhould  not  be  made  fo  tight  as  to  give  much  uneafi- 
nefs,  or  to  endanger  the  circulation,  at  the  fame  time 
that  it  fhould  be  applied  in  fuch  a  manner  as  to  keep 
the  fractured  parts  of  the  bone  in  clofe  contadt. 

During  the  cure,  the  patient  fliould  be  kept  perfeft- 
ly  quiet.  He  fhould  be  fed  entirely  on  fpoon  meat. 
He  fhould  be  enjoined  neither  to  fpeak  or  laugh,  nor 
to  ufe  his  jaws  in  any  manner  of  way.  To  prevent 
the  bones  from  being  difplaced,  which  is  apt  to  hap- 
pen from  frequent  infpeftion,  the  bandage  fhould  be 
applied  with  fuch  attention,  that  there  may  be  no  oc- 
cafion  to  move  it  often.  In  compound  fracture  of  this^ 
part,  there  is  indeed  a  neceffity  for  moving  the  band- 
age daily,  as  the  fore  cannot  otherwife  be  drefled.  It 
fhould  always  be  done,  however,  with  the  utmofh  at- 
tention, an  afTiftant  taking  care  to  fupport  the  parts 
with  his  hands  during  the  whole  time. 

The  management  of  a  fracture  of  one  or  both  jaw 
bones  is  exactly  fimilar ;  only  where  .both  bones  are 
broken,  flill  more  attention  is  required  than  vvhen  one 
only  is  fractured.  In  a  fracture  of  one  of  the  bones, 
the  patient  may  be  allowed  to  eat  foft  meats,  and  to 
fpeak  with  freedom,  in  the  fpace  of  three  weeks  :  but 
where  both  bones  have  fufFered,  this  fhould  not  be 
permitted  till  five  or  fix  weeks  have  elapfed. 


Sed.  V.  Clavicles  mui  Ribs»  337 

SECTION    V. 
Of  Fradures  of  the  Clavicles  and  Ribs. 

THE  clavicles  and  ribs  are  more  liable  to  fraftures 
than  any  other  bones.  This  proceeds,  not  on* 
ly  from  the  flender  ftruclure  of  ihefe  bones,  but  from 
the  pofition  in  which  they  are  placed,  with  their  flat 
fides  expofed  to  every  injury  that  may  be  applied  to 
them. 

A  fracture  of  the  clavicle  is  in  general  eafily  dillin* 
guifhed.  On  the  correfponding  arm  being  fmartly 
moved,  a  grating  noife  is  produced  by  the  ends  of  the 
bone  rubbing  againfl  each  other ;  the  ends  of  the 
fractured  part  readily  yield  to  preflure ;  and,  in  gen- 
eral, the  end  of  the  bone  connected  with  the  humerus, 
is  pulled  to  fome  diftance  from  the  other  by  the  weight 
of  the  arm.  The  motion  of  the  humerus  is  impeded, 
and  fome  degree  of  fwelling,  accompanied  with  more 
or  lefs  pain,  takes  place  over  the  injured  part. 

In  almoft  every  inflance  of  a  fra61:ured  clavicle,  the 
end  conneded  with  the  fternum  is  higher  than  the  oth- 
er, which  has  fuggefted  an  idea  that  has  Very  univer- 
fally  prevailed  in  the  method  of  cure*  Thtf  height  of 
this  part  of  the  bone  is  fuppofed  to  proceed  from  its 
having  ftarted  or  rifen  out  of  its  natural  fituation  :  in 
the  redudion,  therefore,  of  the  fradure,  much  pains 
is  commonly  taken  to  prefs  it  down,  and  very  tight 
bandages  are  employed  to  prevent  it  from  rifmg  dur- 
ing the  cure.  It  will,  however,  be  found,  that  this 
part  of  the  bone  rifes  very  little  out  of  its  natural  fitu- 
ation, and  that  the  appearance  of  its  doing  fo  proceeds 
almoft  entirely  from  the  other  end  of  the  bone  being 
dragged  down  by  the  caufe  I  have  mentioned,  name- 
ly, by  the  weight  of  the  arm.  At  any  rate,  no  ad- 
vantage is  obtained  from  this  pradice :  for  a  force 

Vol.  III.  Y 


338  Of  Fraaures  of  the      Chap.  XXXIX. 

that  would  be  necefTary  for  prefling  dowft  the  end  of 
the  bone,  cannot  be  applied  without  the  effeft  of  cut- 
ting the  teguments,  by  prefling  them  againft  that  part 
of  it  that  is  fuppofed  to  be  raifed ;  while  our  purpofe 
is  fully  anfwered  by  raifmg  the  arm,  and  fupporting 
it  at  a  proper  height.  The  deprefled  portion  of  the 
fractured  clavicle  is  thus  raifed  and  brought  into  con- 
ta£l  with  the  upper  part  of  it.  In  fome  cafes,  indeed, 
of  oblique  fractures,  it  may  be  impofllble  to  bring  the 
ends  of  the  bone  in  every  point  exaftly  oppofite  to 
each  other  :  but  this  may  be  always  fo  far  accomplifh- 
ed  as  to  enable  us  to  avoid  deformity,  and  to  render 
the  bone  fufficiently  flrong. 

When  the  ends  of  the  bone  are  brought  into  con- 
taft,  our  object  is  to  retain  them  in  this  fituation  till 
they  are  united  ;  and,  as  I  have  obferved  above,  this 
can  only  be  done  by  affording  a  proper  fupport  to 
the  arm. 

The  arm  is  ufually  fupported  by  a  fling  hung  round 
the  neck,  adapted  to  the  length  of  the  arm,  and  every 
where  equally  applied  to  it.  But  the  leather  cafe  re- 
prefented  in  Plate  XCVI.  fig.  i.  anfwers  the  purpofe 
with  more  eafe  and  neatnefs.  It  fupports  the  fore- 
arm and  elbow  joint  more  equally  and  more  fecurely  : 
this  lafl,  I  may  remark,  is  a  point  of  no  fmall  impor- 
tance ;  for  if  the  elbow  is  allowed  to  drop,  the  hu- 
merus and  fcapula  will  both  fall  down,  by  which  the 
ends  of  the  fraftured  clavicle  will  again  be  feparated. 

We  are  commonly  directed,  in  the  cure  of  fra£lures 
of  this  bone,  to  have  the  fhoulders  drawn  back  and 
the  head  raifed  ;  and  inflruments  are  defcribed  for 
effecting  thefe  purpofes.  No  general  rule,  however, 
of  this  kind  can  be  given  :  for  in  fome  cafes  the  frac- 
tured parts  of  the  bone  are  kept  exactly  together  when 
the  head  is  bent  down  upon  the  breaft  ;  while  in  oth- 
ers, it  is  better  accomplifhed  when  the  head  and  fhoul- 
ders are  raifed. 

In  other  points,  fractures  of  the  clavicle  mufl  be 
treated  like  fimilar  injuries  in  other  parts  of  the  body. 


Sed.  V.  Clavicles  and  Ribs*  339 

When  fevere  pain  takes  place,  bleeding  with  leeches 
becomes  proper ;  but  in  general,  the  fymptoms  arif* 
ing  from  fradures  of  this  bone  are  of  fo  litile  impor- 
tance, that  the  common  faturnine  applications  prove 
fufficient.  When  the  fradure  is  accompanied  with  a 
wound,  any  fplinters  of  bone  that  may  be  difcovered 
nmfl  be  removed,  and  the  wound  itfelf  dreffed  in  the 
ufual  way.  It  is  proper,  however,  to  remark,  from 
the  vicinity  of  the  fubclavian  artery,  that  the  removal 
of  any  portion  of  the  clavicle  may  be  attended  with 
danger,  and  ought  therefore  to  be  managed  with  cau- 
tion. 

When  the  ends  of  the  fraftured  part  are  properly 
fupportcd,  they  will  in  general  be  firmly  united  in  the 
fpace  of  a  fortnight ;  but  the  correfponding  arm  fliould 
never  be  ufed  with  freedom  till  the  end  of  the  fourth 
or  fifth  week. 

We  difcover  fradures  of  the  ribs  by  the  feat  of  the 
pain,  and  by  prefl'ure  with  xht  fingers.  For  the  mofl 
part,  the  attending  fymptoms  are  moderate  ;  the  pain 
mduced  by  the  fracture  is  inconfiderable,  no  fever  oc- 
curs, and  the  patient  loon  gets  well :  but  hi  fome  in- 
flances  the  pain  is  fevere  from  the  firfl ;  the  breathing 
becomes  difficult,  attended  with  cough  and  perhaps  a 
fpitting  of  blood  ;  and  the  pulfe  is  quick,  full,  and 
fometimcs  oppreflfed. 

It  will  readily  be  underllood,  that  a  fradured  rib 
cannot  of  itfelf  induce  any  of  thefe  fymptoms  :  but  in 
fome  inflanccs  the  ribs  are  not  only  fractured,  but 
pulhed  inwards,  by  which  the  pleura  and  lungs  are 
not  only  comprefTed  but  lacerated  ;  from  which  we 
may  eafily  perceive,  how  pain,  opprefTed  breathing, 
and  fever,  fliould  be  induced  ;  and  from  which  alio 
we  may  account  for  the  emphyfematous  fwellings  de- 
fcribed  in  Chapter  XXI.  Settion  V. 

In  all  cafes  of  fradtured  ribs,  it  is  a  fafe  and  proper 
pradice  to  difcharge  a  quantity  of  blood  proportioned 
to  the  ftrength  of  the  patient.     If  any  inequality  is 
Y  2 


340  Of  Fraaurcs  Chap.  XXXIX. 

difcovered,  by  one  end  of-  the  rib  having  rifen  above 
the  other,  we  (liould  endeavour  by  moderate  equal 
prefTure  to  replace  it  ;  and  to  prevent  it  from  rifmg, 
a  broad  leather  belt  (hould  be  applied  and  drawn  as 
tight  as  the  patient  can  eafily  bear  it.  When  the  belt 
is  properly  lined,  either  with  quilted  cotton  or  flannel, 
it  fits  with  eafe  even  when  tolerably  tight  ;  and  it 
ought  to  be  continued  for  feveral  weeks  after  the  ac- 
cident. 

Even  where  the  fymptoms  have  at  firfl  been  fevere, 
they  commonly  fubfide  upon  the  patient  being  freely 
bled  and  kept  quiet  and  on  a  low  regimen  :  but  where 
the  oppreflfed  breathing  is  kept  up  by  air  efcaping 
from  a  puncture  in  the  furface  of  the  lungs,  or  by 
blood  difcharged  from  a  ruptured  artery  into  the  ca- 
vity of  the  chefl,  or  when  the  pain  is  prevented  from 
fubfiding  by  the  fractured  rib  being  forced  in  upon 
the  pleura  ;  it  becomes  neceflary  to  make  an  opening 
with  a  fcalpel.  Where  a  portion  of  rib  is  merely 
forced  inwards,  the  opening  fhould  be  made  direftly 
upon  the  injured  part ;  and  on  the  rib  being  laid  bare, 
the  deprefled  part  of  it  fhould  be  raifed,  either  with 
the  fingers,  forceps,  or  a  fpatula.  When  the  fymp- 
toms proceed  from  air  or  blood  colle£led  in  the  cavi- 
ty of  the  cheft,  an  opening  fhould  be  made  to  dif- 
charge  them,  in  the  manner  that  I  have  mentioned  in, 
Chapter  XXI.  Section  III.  and  V. 

Fractures  of  the  r'lhs  fhould  in  every  inftance  be 
treated  with  attention ;  but  particularly  where  a  ten- 
dency takes  place  to  phthifis  pulmonalis,  when  the 
irritation  produced  by  a  fradured  rib  is  very  apt  to 
do  harm. 


Scd.  VI.  of  the  Sternum,  341 

SECTION    VI. 

Of  Fradurcs  of  the  Sternum. 

THE  fupport  which  the  ftcrniim  receives  from  the 
ribs,  and  the  degree  of  ehiiticity  of  which  it  is 
polTelTed,  render  it  lefs  liable  than  it  otherwife  would 
be  to  be  hurt  by  external  violence.  It  muft  necefla- 
rily,  however,  be  injured  by  great  degrees  of  force. 
In  fome  cafes  it  is  fradured  without  being  difplaced  ; 
in  others,  it  is  not  only  broken,  but  at  the  fame  time 
beat  in  upon  the  pleura. 

A  fimple  fradure  of  the  fternum  is  to  be  confider- 
ed  in  the  fame  light  with  fimilar  injuries  done  to  the 
ribs,  and  to  be  treated  in  the  fame  manner.  But 
more  danger  is  apt  to  enfue  from  any  portion  of  this 
bone  being  forced  into  the  chefl,  from  the  vicinity  of 
the  large  blood  veflels  of  the  breaft,  while  the  fymp- 
toms  with  which  it  is  accompanied  are  nearly  the 
fame ;  namely,  pain  in  the  injured  part,  cough,  op- 
preffed  breathing,  a  quick  and  fometimes  an  oppreiT- 
ed  pulfe. 

By  fome  we  are  told,  that  the  deprcffed  portion  of 
bone  may  be  raifed  by  defning  the  patient  to  make 
deep  infpirations  ;  by  placing  a  barrel  or  a  drum  un- 
der his  back,  and  keeping  him  lying  for  fome  time  in 
this  poflure  ;  and  by  the  application  of  adhefive  plaf- 
ters  over  the  correfponding  teguments  ;  when,  by  ele- 
vating the  foft  parts,  the  bone  beneath,  it  is  faid,  may 
frequently  be  raifed  along  with  them. 

It  is  not  poffible,  however,  to  fuppofe,  that  much 
advantage  is  to  be  derived  from  any  of  thefe  means  : 
they  may  more  likely,  indeed,  do  harm  ;  nor  would 
I  have  mentioned  them  here,  had  it  not  been  with  a 
view  to  caution  the  younger  part  of  the  profefiion, 
who,  finding  thefe  modes  of  practice  recommended 


342  Of  Fraclures  of        Chap.  XXXIX. 

by  all  the  older  writers,  might  have  been  induced  to 
adopt  them  without  weighing  their  import.  As  the 
(kin  is  no  where  very  intimately  conneded  with  the 
bone  beneath,  it  is  not  probable  that  any  portion  of 
deprefled  bone  will  ever  be  raifed  by  the  external  ap- 
pHcation  of  adhefive  plafters  ;  while,  by  advifmg  deep 
infpirations,  or  laying  the  patient  upon  his  back  over 
a  convex  body,  we  would  often  do  harm,  by  forcibly 
pufhing  the  lungs  againil  the  deprefled  portion  of 
bone. 

When  it  therefore  happens,  that  the  pain,  cough, 
opprefled  breathing,  and  other  fymptoms,  do  not  yield 
to  bloodletting  and  other  parts  of  an  antiphlogiftic 
courfe,  fome  other  method  of  cure  fhould  be  attempt- 
ed. An  incifion  fliould  be  made  upon  the  injured 
part,  of  a  length  fufficient  to  admit  of  a  free  examin- 
ation of  the  bone  ;  when  the  deprefled  piece  may  be 
raifed  with  a  levator,  if  the  opening  will  admit  an  in- 
ftrument ;  or  when  the  opening  in  the  bone  is  not 
fufficiently  large  for  this,  a  perforation  may  be  made 
with  the  trepan,  in  the  manner  I  have  advifed  in 
Chapter  X.  in  fmiilar  injuries  done  to  the  fkull. 

I  know  that  many  will  judge  this  to  be  hazardous ; 
but  when  a  patient  is  in  danger,  either  from  a  portion 
of  deprefled  rib  or  of  the  flernum,  and  which  cannot 
otherwife  be  raifed,  I  would  never  hefitate  in  advifmg 
it.  If  the  operation  is  performed  with  caution,  the 
bone  may  be  raifed  with  fafety  ;  and  this  being  done, 
the  fore  muft  be  treated  in  the  ufual  way.  By  this 
being  neglefted,  either  from  timidity  on  the  part  of 
the  operator,  or  from  any  other  caufe,  many  have  di- 
ed of  phthifis  pulmonalis,  who  otherwife  might  have 
been  faved. 


Sed.  VII.  the  Vertebra^  ^a  343 


SECTION    VU. 

0/  Fractures  of  the  Vertebra,  Os  Sacrum,  Coccyx,  and 
OJfa  Innotnmata. 

FRACTURES  of  the  vertebrse  may  be  produced 
by  falls  and  blows  ;  but  we  meet  with  them  more 
frequently  from  gun(hot  wounds,  than  from  any  oth- 
er caufe. 

For  the  mofl  part,  they  terminate  fatally  :  for  al- 
though many  have  furvived  fuch  fradures  a  great 
length  of  time,  yet  they  generally  linger  and  die  of  the 
confequences.  The  fpinous  and  oblique  procefles  of 
the  vertebrae  may  indeed  be  broken  without  immedi- 
ate danger  ;  but  very  commonly  the  force  by  which 
this  is  efteded,  gives  fuch  a  fhock  to  the  fpinal  mar- 
row, as  at  laft  terminates  in  the  death  of  the  patient : 
and  a  fradure  that  extends  through  the  body  of  a  ver- 
tebra, will  probably,  in  every  inftance,  prove  fatal. 

We  judge  of  the  exiftence  of  this  fraclure,  by  ex- 
ternal examination ;  by  the  force  with  which  it  was 
effedled  ;  by  the  feverity  of  the  pain  ;  and  by  the  parts 
lying  below  the  injured  vertebra  becoming  paralytic 
when  the  fpinal  marrow  has  been  injured. 

When  any  of  the  external  parts  of  the  vertebrae 
are  loofe,  we  may  in  general  replace  them  with  our 
fingers  ;  and,  confinmg  the  patient  as  much  as  poflible 
to  one  pofture,  we  may,  by  means  of  the  napkin  and 
fcapulary  bandage,  retain  them  in  their  fituation  till 
they  unite  with  the  reft  of  the  bone. 

Where  this  cannot  be  done,  a  patient  is  in  general 
left  to  his  fate,  as  it  is  not  fuppofed  that  we  can  with 
fafety  lay  any  of  the  vertebras  bare,  for  the  purpofe  of 
replacing  fuch  parts  of  them  as  may  be  deranged  :• 
but  wherever  the  fpinal  marrow  appears  to  be  com- 
preffed,  and  where  there  is  reafon  to  think  that  the 
comprelfion  is  produced  by  the  depreflion  of  a  portion 


344  Of  Fradurcs  Chap.  XXXIX. 

of  bone,  as  we  know  from  experience  that  every  fuch 
cafe  will  terminate  fatally  if  the  caufe  of  compreliion 
be  not  removed,  it  would  furely  be  better  to  endeav- 
our to  raife  it,  than  leave  the  patient  to  certain  mifery 
and  death.  By  laying  the  injured  parts  freely  open, 
we  may  be  enabled  to  raiie  that  portion  of  bone  by 
which  the  compreffion  is  produced  ;.  while,  in  fuch 
circumllances,  it  cannot  add  to  the  hazard  of  the  pa- 
tient, even  allowing  the  attempt  to  prove  abortive. 

In  a  cafe  where  lymptoms  of  paralyRs  were  induced 
by  a  muiket  bullet  lodged  in  the  fubflance  of  one  of 
the  vertebrae,  a  complete  recovery  was  obtained  by  ex- 
trafting  the  bullet.  A  portion  of  deprefled  bone 
might  often  be  removed  with  equal  eafe  and  fafety  ; 
and  there  is  reafon  to  fuppofe  that  limilar  effeds  would 
often  refult  from  it. 

In  fradures  of  the  os  facrum,  the  method  of  treat- 
ment mufl  be  nearly  fimilar  to  what  I  have  advifed  in 
fradures  of  the  vertebrse  ;  only,  where  the  injury  is 
feated  near  to  the  under  part  of  the  bone,  as  well  as 
in  fradures  of  the  coccyx,  when  any  part  of  it  is  preff^ 
ed  inward,  we  may  in  fome  cafes  be  able  to  replace  it, 
by  pufhing  it  out  with  the  finger  of  one  hand  intro- 
duced into  the  anus,  while  we  co-operate  outwardly 
with  the  other. 

Where  any  of  the  ofla  innominata  are  broken,  if 
the  injury  is  deeply  feated,  the  patient  ought  to  be 
placed  in  that  pofture  in  which  he  finds  himfelf  in 
greateft  eafe,  and  confined  as  much  as  poflible  to  this 
fituation,  till  the  bones  have  time  to  unite.  Blood- 
letting, and  an  attentive  regimen,  fuited  to  his  ftrength 
and  to  the  violence  of  the  fymptoms,  may  prevent 
the  inflammation  that  ufually  fupervenes  from  becom- 
ing fevere. 

In  more  external  fradures  of  thefe  bones,  we  are 
often  enabled  to  replace  fuch  parts  of  them  as  have 
been  forced  out  of  their  fituation,  and  with  the  afiift- 
ance  of  a  proper  bandage,  we  may  alfo  be  able  to  re- 
tain them  till  a  cure  is  completed,     I  have  now  feen 


Setl.  VIII.  of  the  Scapula.  345 

different  inPcances  of  a  confiderable  portion  of  the  ile- 
um being  frattured  and  feparated  from  the  reft,  and 
of  a  cure  being  accompliihed,  by  replacing  the  detach- 
ed parts,  and  retaining  them  with  a  broad  roller  paff- 
ed  feveral  times  round  the  pelvis  and  upper  part  of 
the  thigh. 

With  refpeft  to  the  application  of  this  bandage,  no 
particular  dire£tions  can  be  given  :  it  muft  depend  en- 
tirely on  the  judgment  of  the  praQitioner ;  who  will 
apply  it  in  the  way  that  he  thinks  will  make  it  anfwer 
the  purpofe  of  fixing  the  bones  in  the  fecureft  manner. 


SECTION     VIII. 

Of  FraSlurcs  of  the  Scapula, 

THE  fcapula,  from  its  fituation,  is  not  fo  liable  to 
be  fradured  as  other  bones  ;  but  every  prafti- 
tioner  muft  have  met  with  it.  It  may  be  fradured 
either  in  the  thin  plate,  of  which  it  is  moftly  compof- 
ed  ;  or  in  one  or  other  of  its  procefl'es. 

As  the  motion  of  the  arm  depends  mucli  on  a  found 
and  entire  (tate  of  the  fcapula,  and  as  fractures  of  any 
part  of  it  are  diiiicult  to  cure,  they  very  commonly 
produce  a  ftiff  unwieldy  ftate  of  the  corrcfponding 
arm,  which  in  fome  degree  often  continues  during  the 
life  of  the  patient. 

Fraclures  of  this  bone  are  difcovered  by  the  feat  of 
the  pain  ;  by  the  violence  of  the  injury  ;  by  manual 
examination  ;  and  by  ftiffnefs  and  immobility  in  the 
correfponding  arm.  We  are  told,  that  fradures  of 
the  fcapula  are  apt  to  be  accompanied  with  emphyfe- 
matous  fwellings  ;  but  they  can  only  appear  vvhen  a 
fplinter  of  the  bone  is  forced  into  the  lungs  :  when 
this  takes  place,  air  will  no  doubt  efcape  ;  and  if  it 
paifes  into  the  cellular  fubftance,  emphyfematous  fwell* 
ings  will  neceffarily  occur. 


34^  Of  Fraaures  Chap.  XXXIX. 

In  fradures  of  the  fcapula,  our  firft  objed  Is  to  re- 
place the  fradlured  parts  of  the  bone  with  as  much  ex- 
aftnefs  as  poflible  :  in  doing  fo,  we  are  much  afllfted 
by  relaxing  the  raufcles  of  the  injured  part.  By  raif- 
mg  the  head  and  fhoulders  we  relax  the  mufcles  of 
the  back  ;  and  if,  at  the  fame  time,  the  humerus  is 
fupported,  the  deltoid  mufcle  will  be  fo  much  relax- 
ed, that  any  fradlured  portion  of  the  fcapula  will  be 
more  eafily  replaced.  It  is  always  however  more  dif- 
ficult to  retain  the  bones  during  the  cure,  than  to  re- 
place them  :  for  the  detached  portion  being  in  gener- 
al fmall,  we  can  feldom  retain  it  with  a  bandage.  A 
proper  application  of  a  long  roller  is  perhaps  the  beft 
method  of  doing  it ;  and  in  ufing  this  bandage,  we 
fhould  ftill  take  care  to  have  the  head  and  fhoulders 
fupported,  and  the  arm  fufpended,  fo  as  to  keep  all 
the  mufcles  of  the  injured  part  as  much  as  poflible  re- 
laxed. 

As  all  fractures  are  apt  to  excite  inflammation,  I 
have  elfewhere  obferved,  that  this  fymptom  fliould  at 
all  times  be  guarded  againfl:.  No  where  is  it  more 
neceflary  to  attend  to  this  than  in  fraftures  of  the  fca- 
pula, where  inflammation  is  particularly  apt  to  pro- 
ceed to  an  alarming  height.  Bloodletting  fliould 
therefore  be  freely  praftifed  ;  particularly  local  blood- 
letting with  leeches,  or  cupping  and  fcarifying ;  a  rem- 
edy that  I  confider  as  more  effeftual  than  any  other 
for  the  removal  of  inflammation,  wherever  it  is  feated. 


SECTION    IX. 
Of  Fra&ures  of  the  Humerus. 

IT'RACTURES  of  this  bone  are  eafily  difcovered, 
as  no  part  of  it  is  thickly  covered  with  foft  parts  ; 
oblique  fractures  become  evident  to  the  fight,  but  ev- 


Se£l.  IX.  of  the  Humerus.  347 

en  thofe  that  are  perfedly  tranfverfe  become  immedi- 
ately obvious  on  the  llighteft  manual  examination. 

In  the  redudion  of  fractures  of  this  bone,  we  do 
not  find  that  much  extenfion  is  required  ;  but  that  it 
may  be  done  with  eafe,  the  mufcles  of  the  arm  fliould 
be  put  as  much  as  pollible  into  a  flate  of  relaxation ; 
this  we  do  by  moderately  bending  the  elbow,  while 
the  limb  is  raifed  nearly  to  a  horizontal  direction,  and 
not  carried  fo  much  forward  as  to  put  the  latiilimus 
dorfi,  infcrted  into  the  back  part  of  it,  on  the  flretch, 
or  too  far  back  to  ftretch  the  pectoral  mufcle. 

The  patient  being  properly  placed,  and  the  arm  put 
in  this  fituation,  the  furgeon  will  in  general  be  able  to 
replace  the  bones  without  any  afliflance  ;  but  when 
extenfion  is  neceflary,  it  may  be  applied  by  one  aflift- 
ant  grafping  the  arm  between  the  fradure  and  joint  of 
the  fhoulder,  and  another  above  the  elbow. 

In  this  manner  the  fradured  parts  of  the  bone  are 
to  be  replaced  ;  and  with  a  view  to  fecure  the  fradur- 
ed  parts  in  their  fituation,  a  firm  fplint,  fuch  as  is  re- 
prefented  in  Plate  LXXXI.  figs.  5.  and  6.  fhould  be 
placed  on  the  outfide  of  the  arm,  and  another  along 
the  infide  of  it,  each  of  them  covered  with  foft  flan- 
nel, to  prevent  them  from  galling  the  Ikin  ;  and  while 
thefe  are  fecured  by  one  alliflant,  and  the  fore-arm 
fupported  by  another,  a  flannel  roller  fhould  be  appli- 
ed over  the  whole,  of  fuch  tightnefs  as  to  fupport  the 
ends  of  the  frattured  bone,  without  interrupting  the 
circulation  of  the  limb. 

The  fore-arm  fhould  be  fupported  in  a  fling,  fuch 
as  is  reprefented  in  Plate  XCVI.  fig.  i.  and  the  pa- 
tient may  be  either  put  to  bed  or  allowed  to  fit,  as  is 
mofl  agreeable  to  himfelf.  It  may  not,  however,  be 
improper  to  remark,  that  it  anfwers  better  to  have  the 
arm  in  a  hanging  pofition  than  laid  horizontally  on  a 
pillow  ;  particularly  in  oblique  fraftures  of  this  bone, 
in  which  the  weight  of  the  limb  has  a  confiderable  ef- 
fect in  pi-eventing  the  ends  of  the  bone  from  over  lap- 
ping or  palTmg  each  other.    Even  in  bed,  therefore, 


34^  Of  Fraaures  of  the        Chap.  XXXIX. 

where  there  is  any  danger  of  this,  the  patient  fliould 
be  placed  in  fuch  a  manner  that. his  arm  may  hang, 
inftead  of  being  laid  in  the  ufual  way  upon  a  pillow. 
In  tranfverfe  fraclures,  this  precaution  is  not  fo  necef- 
fary,  as  the  ends  of  the  bone,  if  once  replaced,  ferve 
in  ibme  meafure  to  fupport  each  other.  But  even  in 
thefe,  it  is  the  bell  practice  to  fupport  the  fore-arm  in 
fuch  a  manner  that  it  may  have  fome  effect  in  pulling 
the  under  part  of  the  humerus  gently  downwards. 

When  no  urgent  fymptom  takes  place,  fuch  as  much 
pain  and  fwelling  of  the  arm,  the  bandage  fliould  not 
be  moved  for  feveral  days :  but  about  the  feventh  or 
eighth  day,  it  is  proper  in  every  fracture  to  remove 
all  the  coverings,  in  order  to  fee  whether  the  bone .  is 
perfectly  in  its  place  or  not ;  for  at  this  period,  any 
accidental  difplacement  may  be  eafily  put  right,  and 
a  cautious  inl'pedion  may  be  made  with  fafety. 

I  have  advifed  a  roller  to  be  employed  for  fractures 
of  this  bone  ;  and  perhaps  it  is  the  only  inftance  in 
fractures  of  the  large  bones  of  the  extremities  in  which 
it  fhould  be  preferred  to  the  twelve  tailed  bandage. 
But  whoever  has  ufed  them  both  will  find,  that  in  fim- 
ple  fradtures  of  the  humerus,  the  roller  is  not  only 
more  eafily  applied  than  the  other,  but  that  it  anfwers 
the  purpofe  better. 

Fractures  of  the  humerus  commonly  heal  more 
Jdndly  than  fimilar  injuries  of  any  other  bone  ;  and 
when  properly  managed,  they  feldom  leave  either  lame- 
nefs  or  diftortidn  of  the  arm.  When  no  interruption 
occurs  to  the  cure,  cither  from  fevere  pain,  fwelling, 
or  inflammation,  or  from  accident  or  mifmanagement, 
the  bone  will  in  general  be  firmly  united  in  lefs  than 
a  month  ;  but  the  limb  Ihould  not  be  ufed  with  free- 
dom till  fix  or  feven  weeks  have  elapfed. 


1 


SqO:.  X»  Bones  of  the  Fore- Arm.  349 

SECTION    X. 

Of  Fradures  of  the  Bones  of  the  Fore-Arm^ 

THE  bones  conipofing  the  fore-arm  are  two  in 
number,  the  radius  and  uhia.  Being  much  ex- 
pofed  to  injuries,  they  are  very  Hable  to  fractures. 
When  both  bones  are  broken,  the  nature  and  feat  of 
the  injury  at  once  become  obvious  ;  but  when  one 
bone  only  is  fraftured,  efpecially  the  radius,  as  the 
firmnefs  of  the  uhia  keeps  it  on  the  ftretch,  and  pre- 
vents it  from  being  difplaced,  we  do  not  fo  eafily  per- 
ceive the  injury  :  the  feat  of  the  pain  points  out  the 
injured  part ;  and  when  either  of  the  bones  is  fraclur- 
ed,  a  grating  noife  will  be  heard  if  the  furgeon  grafps 
the  limb  firmly  above  and  below  this  part,  and  endeav- 
ours to  move  it  in  different  directions. 

In  this  examination,  it  is  of  much  importance  to 
diftinguifh  the  direction  of  the  fracture  with  as  much 
exactnefs  as  pofilble,  particularly  if  near  to  the  wrift ; 
for  upon  this  the  chance  of  our  making  a  perfeO:  cure 
in  a  great  meafure  depends  ;  and  in  this  fituation, 
whether  both  bones  or  only  one  of  them  is  broken, 
much  attention  is  required  to  prevent  the  ftiff  uneafy 
ftate  of  the  arm  from  continuing  long  after  the  bones 
are  united  :  patients  indeed  often  complain  of  this,  in 
fome  cafes  during  life  ;  and  I  think  it  more  frequent- 
ly happens  when  the  radius  is  broken  by  itfelf  than 
when  the  ulna  only  is  fractured,  owing,  I  fuppofe,  to 
the  radius  having  a  rotatory  motion  independent  of 
the  other,  by  which  it  is  not  fo  eafily  kept  in  its  fitu- 
ation. And  as  there  is  nothing  for  which  praftition- 
ers  are  more  apt  to  be  blamed  than  for  thole  inconve- 
nicncies  that  fucceed  to  fradures,  we  ought  in  every 
inifance  to  be  as  much  as  poflible  on  our  guard  againft 
them. 


350  Of  Fractures  ofihe        Chap.  XXXIX.- 

On  the  feat  of  the  injur}'^  being  difcovered,  {i  any 
part  of  either  of  the  bones  is  difplaced,  we  ought,  as- 
foon  as  it  can  be  done,  to  put  it  right.  The  patient 
being  properly  feated,  and  the  mufcles  of  the  arm  re- 
laxed by  gently  bending  the  joints  of  the  wrift  and 
elbow,  the  fore-ann  fhould  be  extended  to  fuch  a  de- 
gree, by  one  affiftant  grafping  it  above  the  fradure, 
and  another  below,  as  is  juft  fufficient  to  allow  the 
furgeon  to  replace  the  bones.  This  being  done,  one 
of  the  fplints  reprefented  in  Plate  LXXXl.  fig.  3.  4. 
or  5.  covered  with  foft  flannel,  and  of  a  length  tO' 
reach  from  the  elbow  to  the  tops  of  the  fingers,  and 
of  fuch  a  breadth  as  to  incafe  rather  more  than  one 
half  of  the  arm  and  hand,  fhould  be  placed  along  the 
ulna.  Another  fplint  not  quite  fo  broad  mufl  be 
placed  along  the  courfe  of  the  radius  ;  vihen  both 
mufl  be  fecured  either  with  a  flannel  roller  or  a  twelve 
tailed  bandage,  with  fuch  tightnefs  as  may  prevent  the 
bones  from  flipping  out  of  their  place,  but  without 
impeding  the  circulation,  or  exciting  any  degree  of 
pain.  In  all  fimple  fraftures  of  thefe  bones,  the  twelve 
tailed  bandage,  and  fimple  roller,  may  be  ufed  with 
perhaps  equal  propriety. 

In  applying  the  fplints,  the  pahii  of  the  hand  fhould 
be  turned  towards  the  breaft,  this  being  not  only  the 
mofl  convenient  pofture  in  which  the  arm  can  hang 
while  in  a  fling,  but  the  befl  in  which  it  can  at  all 
times  be  placed,  even  when  the  patient  is  in  bed :  for 
in  this  fituation  the  palm  of  the  hand  can  neither  be 
turned  up  nor  down  ;  that  is  it  can  neither  be  put  in- 
to a  prone  nor  a  fupine  poflure,  without  giving  that 
rotatory  motion  to  the  radius  that  I  have  mentioned, 
and  which  tends  more  than  any  other  to  difplace  any 
part  of  this  bone  that  may  be  fraftured.  It  fhould 
therefore  be  avoided  j  and  I  know  of  no  way  in  which 
it  can  with  fuch  certainty  be  done,  as  fecuring  the 
arm  with  fplints  in  the  manner  I  have  mentioned  :  it 
fhould  now  be  hung  in  the  fling  reprefented  in  Plate 
XCVI.  fiiT.  I.  and  allowed  to  remain  in  the  leather 


Seft.  X.  Bones  of  the  Fore- Arm,  351 

cafe  during  the  night,  or  in  any  fmall  box  of  a  fimi- 
lar  conflru^iion,  and  of  a  fi^e  jufl  fufficient  to  receive 
the  arm  when  placed  upon  its  fide,  but  without  per- 
mitting it  to  turn  either  one  way  or  another. 

In  fpeaking  of  the  fplints,  I  have  advifed  them  to 
be  of  a  fufficient  length  for  (tretching  along  the  whole 
courfe  of  the  arm  from  the  elbow  to  the  top  of  the 
fingers.  The  under  fplint  ought  more  efpecially  to 
be  of  this  length  ;  for  the  arm  not  only  refts  with 
more  eafe  and  equality  upon  a  long  fplint,  but  it  ferves 
to  cover  the  fmgers,  by  which  they  are  prevented  more 
effedually  than  in  any  other  manner  from  moving ;  a 
circumftance  of  much  importance  in  every  fradure  of 
the  fore-arm  :  for  when  a  free  motion  of  the  fingers 
is  permitted,  it  not  only  tends  to  keep  up  inflamma- 
tion and  pain,  but  is  often  the  caufe  of  the  bones 
being  again  difplaced,  when  othenvife  they  might 
have  been  kept  in  contact. 

A  partial  diflocation  of  the  bones  forming  the  joint 
of  the  wrift,  is  not  an  unfrequent  concomitant  of  frac- 
tures of  the  radius  ;  from  a  combination  of  which, 
there  is  always  much  rifk  of  fliffnefs  being  left  in  the 
joint,  and  of  a  painful  permanent  fwelling  over  the 
under  part  of  the  arm  :  with  this  the  patient  fhould 
always  be  made  acquainted  ;  for  even  under  the  befl: 
management,  a  difl'ocation  of  the  wrift,  accompanied 
with  a  frafture  of  the  contiguous  bones,  commonly 
ends  in  this  manner :  for  the  method  of  reducing  the 
diflocation,  I  muft  refer  to  the  enfuing  Chapter ;  and 
I  have  already  pointed  out,  in  the  firft  Sedion  of  this 
Chapter,  what  I  conceive  to  be  the  beft  method  of 
preventing  and  removing  inflammation  ;  which  I  have 
there  (hewn  to  be  the  moft  frequent  caufe  of  that 
ftiff  immoveable  ftate  in  which  fradured  hmbs  ai'e  of- 
ten left. 

The  olecranon,  or  upper  end  of  the  ulna,  is  fome- 
times  fra£lured  without  any  injury  being  done  to  the 
reft  of  the  bone ;  this  part  of  the  bone  being  particu- 


352  Of  Fraaures  of  the         Chap.  XXXIX. 

larly  apt  to  fufl'er  from  falls  and  bruifes  upon  the  el- 
bow. 

In  this  cafe,  in  order  to  keep  the  fradured  parts  in 
contadt,  the  fore-arm  muft  be  extended :  and  with  a 
view  to  preferve  the  arm  in  this  fituation,  a  long  fplint 
fhould  be  laid  along  the  forepart  of  it,  from  the  up- 
per part  of  the  humerus  to  the  tops  of  the  fingers ; 
and  this  being  fecured  with  a  roller,  the  arm  fhould 
be  allowed  to  hang  by  the  fide,  to  which  it  fhould  be 
fixed  with  one  or  two  ftraps. 

It  is  proper,  however,  to  remark,  that  it  fhould  not 
be  long  kept  in  this  fituation,  otherwife  a  fliffnefs  of 
the  elbow-joint  would  enfue  :  with  a  view  to  the  pre-- 
vention  of  this,  the  bandage  and  fplint  fhould  be  re- 
moved about  the  eighth  or  tenth  day  ;  when  the  fore- 
arm being  for  fome  time  moved  flowly  backward  and 
forward,  and  the  joint  rubbed  with  any  emollient  oil, 
the  arm  fhould  be  again  fecured  as  before.  A  cau- 
tious and  daily  repetition  of  this,  while  it  prevents  a 
ftiff  joint,  does  not  retard  the  cure. 


SECTION     XI. 


Of  Fra&ures  of  the  Bo?ies  of  the  Wrtfl,  Hands,  and 
Fingers* 

THE  bones  of  the  wrifl  being  fmall,  round,  and 
fomewhat  moveable,  readily  yield  to  any  ordi- 
nary force  that  may  be  applied  to  them.  On  this  ac- 
count, they  are  feldom  fractured,  except  by  fhot  from 
firearms,  or  a  heavy  weight  paffing  over  them. 

Thefe  bones  are  fo  fmall  that  when  fradured,  they 
are  not  eafily  retained  in  fitu^  and  do  not  therefore 
unite  fo  readily  as  bones  of  a  larger  fize.  For  this 
reafon,  as  well  as  from  the  contiguity  of  numerous  lig- 
aments and  tendons,  which  gives  rife  to  high  degrees 
of  inflammation,  a  complete  anchylofis,  or  great  ftiff- 


Sea.  XL         Bones  of  the  Wri/i,  ^c.  353 

nefs  of  the  joint,  often  fucceeds.  v^fter  replacing  the 
bones,  thefe  confequences  are  with  moft  certainty 
guarded  againft,  by  a  copious  difcharge  of  blood  from 
the  injured  parts  by  means  of  leeches  ;  and  this  being 
done,  the  arm  and  hand  (liould  be  well  fupported  by 
a  fplint  beneath,  and  another  above,,  in  th^  manner 
advifed  in  the  lafl  fe6lion. 

In  fradlures  of  the  metacarpal  bones,  after  being  re- 
placed with  accuracy,  a  firm  fplint,  either  of  timber 
or  flrong  pafteboard,  (liould  be  applied  over  the  whole 
palm  of  the  hand  and  infide  of  the  arm,  from  the  ends 
of  the  fingers  to  the  joint  of  the  elbow,  in  order  to 
keep  the  hand  in  a  flate  of  extenfion,  as  the  flexor 
mufcles  of  the  lingers  cannot  be  bent  without  altering 
the  pofition  of  thcfe  bones :  and  that  this  may  with 
certainty  be  done,  the  long  fpUnts  mentioned  above, 
fecured  with  a  fnnilar  bandage,  fhould  be  applied  over 
the  whole. 

Fra£lures  of  the  bones  of  the  fingers  are  frequent ; 
but  when  properly  treated,  they  readily  unite,  and  the 
fingers  become  equally  ufeful  as  before. 

The  befl  fplint  for  a  fradured  finger  is  a  piece  of 
firm  pafteboard  fitted  to  it  with  accuracy,  and  foften- 
ed  in  water  till  it  is  eafily  moulded  to  the  form  of  the 
part.  The  finger  being  ftretched  out  and  the  bone 
replaced^  this  fplint  iliould  be  applied  along  the  whole 
length  of  it,  and  fecured  with  a  narrow  roller.  In  or- 
der to  prevent  the  injured  parts  from  being  difturbed, 
a  large  fplint,  either  of  the  fame  kind  of  pafteboard, 
or  of  a  thin  piece  of  wood  glued  upon  leather,  as  is 
reprefented  in  Plate  LXXXI.  figs.  3,  4,  5,  or  6,  fhould 
be  applied  over  the  infide  of  the  hand  ;  and  the  fin- 
gers being  ftretched  upon  it,  another  roller  fhould  be 
put  over  the  whole,  to  fecure  the  fingers  and  hand,  fo 
as  entirely  to  prevent  motion. 

With  a  view  to  preferve  the  motion  of  the  finger 
joints,  the  bandage  and  fplints  fliould  be  removed 
about  the  tenth  or  twelfth  dav  j  when  all  the  joints 

Vol.  III.  Z 


354  Of  Fraaurcs  of  the       Chap.  XXXIX* 

being  frequently  bent  and  extended,  the  whole  fhould 
be  tied  up  as  before  :  and  this  being  repeated  daily, 
the  fplints  may  with  fafety  be  removed  at  the  end  of 
the  third  week  ;  when,  by  this  piece  of  attention,  the 
motion  of  the  finger  will  be  found  complete,  unlefs 
more  than  one  bone  has  been  broken,  and  at  the  fame 
time  feverely  fplintered. 


SECTION     XII. 

Of  Fractures  of  the  Femur  or  Thigh  Bone* 

WE  meet  with  fraclures  in  every  part  of  the  fe- 
mur ;  but  more  frequently  in  the  middle 
than  in  any  other  part  of  it :  next  to  this,  that  part  of 
it  which  we  term  the  neck  of  the  femur,  is  mod  apt 
to  be  fradured. 

Fractures  of  all  the  under  part  of  this  bone  are  for 
the  mofl  part  eafily  diftinguiflied,  by  the  ufual  grating 
noife  produced  by  the  ends  of  it  being  forcibly  rub- 
bed together  ;  by  the  limb  being  much  Ihortened  if 
the  fradure  is  oblique,  or  the  ends  of  the  bone  dif- 
placed  where  the  fradure  is  tranfverfe  ;  by  much  pain 
and  tenfion  over  the  injured  part ;  and  by  the  limb 
being  rendered  unable  to  fullain  the  weight  of  the 
body. 

It  is  often  difficult,  however,  to  diflinguifh  fraftures 
of  the  neck  of  the  femur  from  diflocations  of  this 
bone ;  but  a  due  attention  to  the  following  circum- 
ftances  will  enable  us  for  the  mod  part  to  avoid  mif- 
takes  in  regard  to  this,  which  are  always  attended  with 
ferious  confcquences. 

In  a  great  proportion  of  cafes,  perhaps  in  ninety- 
nine  of  every  hundred,  the  head  of  the  femur  when 
diflocated  is  pufhed  inwards  and  downwards,  owing  to 
the  brim  of  the  acetabulum  being  not  fo  deep  in  this 


Sed.  XII.  Femur  or  TJj'igh  Bone.  355 

part  as  in  others  ;  while  in  fradures  of  the  neck  of 
the  femur,  the  bone  has  in  every  inftance  that  I  have 
feen  of  it  been  drawn  upwards,  and  the  leg  thereby 
rendered  fhorter  by  three  or  four  inches,  in  confe- 
quence  of  the  powerful  exertion  of  the  glutasi  mufcles 
on  a  bone  deprived  of  its  ordinary  fupport.  In  all 
fuch  cafes,  therefore,  the  trochanter  is  found  to  be 
much  higher  than  the  trochanter  of  the  other  thigh  ; 
and  the  knee  and  points  of  the  toes  turned  inwards  ; 
while  in  thofe  diflocations  of  the  thigh  joint  that  I  have 
mentioned,  the  leg  is  much  lengthened,  the  head  of 
the  bone  is  found  in  the  groin,  and  the  trochanter  is 
difcovered  on  the  forepart  of  the  thigh,  while  a  cor- 
refponding  vacancy  is  perceived  where  the  trochanter 
and  head  of  the  bone  Ihould  be,  and  the  toes  are  turn- 
ed outwards. 

In  every  frafture,  a  grating  noife  is  difcovered  on 
the  ends  of  the  bone  being  rubbed  againft  each  other  ; 
and  in  all  fractures  of  the  neck  of  the  femur,  we  ob- 
ferve,  that  the  leg  and  thigh  may  be  turned  with  much 
more  eafe  from  one  fide  to  another,  that  is,  the  knee 
and  foot  may  be  moved  witli  more  eafe  outwards  or 
inwards,  than  when  the  head  of  the  bone  is  diflocated. 
I  may  Hkewife  remark,  that,  in  diflocations,  the  tumor 
formed  by  the  head  of  the  bone  and  trochanter  to- 
gether, mud  aKvays  be  larger  than  in  fradlures,  where 
the  tumor  is  formed  by  the  trochanter  alone. 

In  no  part  of  furgery  are  practitioners  more  apt  to 
be  difappointed  than  in  the  treatment  of  fractures  of 
the  thigh,  particularly  where  the  neck  of  the  bone  is 
broken.  This  proceeds  from  various  caufes  ;  all  of 
which  fliould  be  kept  in  view  in  forming  a  prognofis 
of  the  event. 

1.  The  thigh  bone  is  fo  thickly  covered  with  muf- 
cles and  other  foft  parts,  that  it  is  often  difficult  to  dif- 
cover  the  direction  in  which  a  fracture  runs. 

2.  We  muft  often,  therefore,  be  uncertain  whether 
the  bones  are  rightly  replaced  or  not  j  for  where  the 

z  2 


^^6  Of  Fraaures  of  the       Chap.  XXXIX. 

courfe  of  a  fracture  cannot  be  afcertained,  we  can  nev- 
er be  fure  whether  this  is  rightly  done  or  not. 

3.  But  even  where  the  reduction  of  the  fradure 
can  be  accompUfhed,  we  know  from  daily  obfervation 
that  it  is  difficult  to  retain  the  different  parts  of  the 
bone  in  their  fituation  with  fuch  exadtnefs  as  to  pre- 
vent deformity.  For  when  the  fradure  is  either  in 
the  neck  of  the  bone,  or  runs  obliquely  in  any  other 
part  of  it,  it  is  fo  difficult  to  prevent  the  fraftured  parts 
of  it  from  being  difplaced  merely  by  the  ordinary  ac- 
tion of  the  mufcles,  that  the  limb  for  the  mod  part  be- 
comes much  fhorter  than  the  other ;  for  in  all  fuch 
cafes,  if  the  different  parts  of  the  bone  cannot  be  fo 
placed  and  retained  as  to  fupport  each  other,  the  un- 
der part  of  it  will  very  certainly  be'drawn  upwards. 

In  all  thefe  fraftures  too,  other  caufes  concur  to 
render  it  difficult  to  retain  the  fraftured  parts  of  the 
bone  in  their  fituation.  They  are  more  eafily  afted 
upon  than  fradures  of  other  bones  by  every  exertion 
of  the  body  ;  particularly  by  fneezing,  coughing,  and 
laughing ;  nor  can  the  pofture  of  the  body  be  in  any 
way  altered  without  moving  the  thigh. 

Till  of  late,  pradtitioners  were  often  difappointed  in 
their  endeavours  to  reduce  fra61:ures  of  the  femur  ; 
chiefly  ov/ing  to  the  pofition  in  which  the  limb  was 
put  during  the  operation.  The  body  being  placed  ei- 
ther upon  the  floor,  on  a  table,  or  in  a  bed,  the  limb 
was  then  extended,  by  which  all  the  mufcles  of  the 
limb  were  put  upon  the  flretch  ;  and  as  the  extenfion 
was  continued  till  the  different  parts  of  the  bone  were 
replaced,  when  this  was  difficult,  the  mufcles  were 
often  either  violently  torn  afunder,  or  fo  much  weak- 
ened as  not  to  be  afterwards  fit  for  ufe  ;  for  fome  of 
the  mufcles  of  the  thigh  being  among  the  ftrongefl  of 
the  body,  a  very  confiderable  force  was  required  to 
overcome  their  refiffance.  But  if  the  mufcles  of  the 
limb  are  relaxed,  by  making  the  thigh  form  an  obtufe 
angle  with  the  body  while  the  joint  of  the  knee  is 
moderately  bent,  it  is  furprifnig  with  what  eafe  we 


Seel.  XII.  Femur  or  Thigh  Bone.  357 

may,  in  mod  cafes,  place  the  fra£lured  end  of  the 
bone  in  its  fituation.  The  caufe  of  refiftance  is  thus 
ahnofl  entirely  removed  ;  fo  that  if  much  tenfion  or 
fwelling  have  not  taken  place,  the  ends  of  the  bone 
may  in  general  be  eafily  brought  in  contadl,  by  one 
affiftant  fecuring  the  upper  end  of  it,  while  the  under 
part  of  it  is  fupported  and  gently  drawn  down  by 
another,  the  furgeon  in  the  mean  time  being  employ- 
ed in  putting  the  fradured  parts  together  with  as  much 
accuracy  as  poflible. 

Fradures  of  the  neck  of  this  bone  are  particularly 
difficult  to  reduce  ;  for  the  mufcles  being  here  exceed- 
ingly ftrong,  and  running  in  various  direftions,  they 
cannot  be  relaxed  fo  completely  as  thofe  in  other  parts 
of  the  limb.  But  even  here  we  may,  for  the  mofl 
part,  fucceed  in  the  manner  I  have  mentioned,  the 
body  being  fecured  by  one  affiftant,  while  moderate 
extenfion  is  made  by  another  at  the  under  part  of  the 
thigh.  Praditioners  ought,  however,  to  be  provided 
with  inftruments  for  more  powerful  extenfion  when 
more  lenient  meafures  do  not  fucceed.  Different  in- 
ftruments are  delineated  for  this  purpofe  in  Plates 
LXXXVII.  LXXXVIII.  and  LXXXIX.  but  none  of 
them  fliould  ever  be  employed  till  other  more  gentle 
means  have  failed. 

It  is  not,  however,  in  replacing  the  bones,  but  in 
retaining  them  when  replaced,  that  we  moft  frequent- 
ly fail.  In  tranverfe  fradures  of  this  bone,  the  prac- 
tice is  eafy.  After  the  fradured  ends  of  it  are  brought 
in  contact,  they  would  for  the  moft  part  fupport  each 
other  with  fufficient  firmnefs  even  without  a  bandage, 
if  the  patient  fiiould  be  confined  to  a  proper  pofture  ; 
but  to  prevent  any  rifk  from  fudden  exertions,  the 
parts  fhould  be  as  firmly  fecured  with  fplints  and  a 
proper  bandage,  as  is  confiftent  with  a  free  circulation 
through  the  reft  of  the  limb. 

For  this  purpofe  two  fplints  are  reprefented  in  Plate 
LXXXI.  fig.  4.  and  6.  One  to  reach  from  the  top 
of  the  hip  joint  to  a  little  below  the  knee,  and  of 


358  Of  Fraaures  of  the       Chap.  XXXIX. 

a  breadth  fufficient  to  cover  at  leaft  one  half  of  the 
thigh  ;  the  other  to  reach  from  the  groin  to  a  little 
below  the  knee,  and  in  breadth  to  cover  about  a  third 
part  of  the  thigh.  Of  thefe,  covered  with  foft  flan- 
nel, the  longeft  laid  upon  a  twelve  tailed  flannel  band- 
age, is  to  be  placed  upon  a  thin  pillow  nearly  as  long 
as  the  thigh.  The  patient  being  previoufly  laid  on  a 
firm  hair  mattrefs  fupported  by  firm  fpokes  of  timber, 
fo  that  the  hmb  may' not  fmk  or  yield,  his  knee  being 
moderately  bent,  and  the  bones  accurately  fet,  the  pil- 
low with  the  bandage  and  fplint  above  it  ought  to  be 
placed  fo  that  the  fplint  may  reach  from  the  hip  joint 
along  the  outfide  of  the  thigh  to  the  knee.  That  this 
pofliure  of  the  leg  and  thigh  may  be  eafily  preferved, 
the  patient  fliould  not  be  laid  diredly  upon  his  back, 
but  turned  fomewhat  towards  the  injured  fide  ;  and 
the  knee  and  leg  raifed  rather  higher  than  his  body. 

The  limb  being  thus  placed  in  the  pollure  in  which 
it  is  to  be  kept,  the  fiiort  fplint  mentioned  above  muft 
be  laid  along  the  infide  of  the  thigh  from  the  groin 
to  the  knee,  when  the  twelve  tailed  bandage,  previouf- 
ly placed  beneath  the  other  fplint,  muft  be  applied 
with  fuch  tightnefs  as  to  make  an  equal  degree  of 
preflfure  over  the  whole  thigh. 

As  the  cure  would  be  much  interrupted,  and  might 
even  at  laft  be  incomplete,  were  any  part  of  the  drefl- 
ings  to  yield,  it  is  a  right  precaution  perhaps  in  every 
cafe,  to  infert  a  long  fplint  of  firm  timber  beneath  the 
pillow,  and  to  fecure  it  in  its  fituation  with  two  broad 
flraps  firmly  buckled  on  the  upper  part  of  the  limb. 

To  obviate  the  motion  of  the  limb,  in  confequence 
of  involuntary  ftartings,  the  pillow  fhould  be  fixed  to 
the  bed  by  flraps  ;  and  to  prevent  injury  or  uneafmefs 
from  the  weight  of  the  bedclothes,  two  or  three  hoops 
fixed  in  a  frame  fhould  be  placed  over  the  thigh. 

When  no  untoward  fymptoms  occur,  the  limb 
mi'Sjht  be  left  in  this  fituation  till  the  cure  is  complete ; 
but  left  the  bones  fhould  by  accident  be  difplaced,  and 
cfpecially  if  the  limb  fhould  fwell  and  become  painful. 


Se£b.  XII.  Femur  or  TJj'igh  Bone.  359 

the  bandage  fhould  occafionally  be  undone,  and  the 
upper  fplint  removed,  with  a  view  to  admit  of  the  parts 
being  accurately  examined  ;  and  the  twelve  tailed 
bandage  admits  of  this,  without  difturbing  the  limb. 
When  pain,  fwelling,  or  much  inflammation,  fuper- 
vene,  it  may  be  proper  to  apply  leeches  and  other  rem- 
edies to  the  injured  parts  ;  but  when  this  does  not  hap- 
pen, and  when  the  bones  remain  in  their  fituation,  the 
fplint  fliould  be  immediately  replaced  and  fecured  with 
the  bandage  as  before. 

In  healthy  adults,  when  no  interruption  occurs  to 
It,  the  cure  is  in  general  complete  in  the  courfe  of  fix 
weeks  ;  but  violent  exertion  of  every  kind  fliould  be 
avoided  till  the  eighth  or  tenth  week  has  pafled  over. 

I  have  advifed  the  limb  to  be  placed  in  fuch  a  pof- 
ture  as  tends  with  mofl  effed  to  relax. the  mufcles  that 
belong  to  it.  But  although  this  may  be  highly  pro- 
per at  fnfl,  there  is  no  neceflity  for  the  fame  poflure 
being  continued  during  the  whole  courfe  of  the  cure. 
It  often  indeed  proves  hurtful,  as  the  limb,  when  kept 
invariably  in  one  pofture  for  fix  or  eight  weeks,  as  is 
too  frequently  done,  is  very  apt  to  become  fliff  and 
unwieldy,  fo  as  afterwards  to  give  much  uneafmefs 
and  diftrefs.  In  a  fimple  frafture,  the  patient  may, 
at  the  end  of  a  fortnight,  be  allowed  to  turn  more  to- 
wards his  back,  and  the  joint  of  the  knee  may  be 
fomewhat  llretched  out.  If  this  is  done  with  caution, 
it  may  be  repeated  daily  ;  that  is,  the  leg  may  be  al- 
ternately ftretched  out  and  bent ;  by  which  the  mo- 
tion of  the  whole  limb  will  be  much  more  free  and 
entire  at  the  end  of  the  cure  than  we  ufually  fmd  it  to 
be  :  but  where  the  bones  of  a  limb  are  broken  in  fev- 
eral  parts,  and  into  fmall  pieces,  the  limb  fhould  not 
be  raifed  nor  moved  in  any  manner  of  way  till  five  or 
fix  weeks  have  elapfed  j  and  then  only  with  much 
caution. 

In  a  great  proportion  of  cafes  in  which  cures  are 
practicable,  this  courfe  of  treatment  will  prove  fuccefs- 
ful.     It  will  never  fail  in  tranfverfe  fradlures,  if  all  the 


360  Of  Fraaurcs        Chap.  XXXIX. 

parts  of  It  meet  with  proper  attention :  but  although 
it  will  often  fucceed  even  where  the  bone  is  broken 
obliquely  ;  yet  it  mufl  be  confefled,  that  cafes  fome- 
times  occur  in  which  it  fails  entirely  ;  the  ends  of  the 
bone  flip  pad  each  other,  and  the  limb  becomes  much 
fliorter  than  it  ought  to  be,  notwithllanding  all  our 
eftbrts  to  prevent  it. 

An  elFeclual  method,  indeed,  of  fecuving  oblique 
fractures  in  the  bones  of  the  extremities,  and  efpeciaU 
ly  of  the  thigh  bone,  is  perhaps  one  of  the  greatefk 
defiderata  in  modern  furgery.  In  all  ages,  the  diifi- 
culty  of  this  has  confefl'edly  been  great ;  and  frequent 
lamenefs  produced  by  fliortened  limbs  arifmg  from 
this  caufe,  evidently  fliows  that  we  are  (till  deficient 
in  this  branch  of  practice. 

The  treatment  of  fractures  being  one  of  the  mod 
important  branches  of  furgery,  and  to  prevent  lame- 
nefs, one  of  our  firft  objects,  nmch  ingenuity  has  been 
fhown  in  the  invention  of  means  for  anfwering  this 
purpofe  :  it  has  been  propofed,  and  by  many  attempt- 
ed, in  fractures  of  the  thigh,  to  fecure  the  patient's 
body,  at  one  fixed  point,  with  different  bandages,  to 
the  upper  part  of  the  bed,  and  by  an  axis  in  peritro- 
chio  at  the  foot  of  the  bed,  to  make  fuch  a  degree 
of  extenfion  as  might  be  fully  equal  to  the  purpofe  of 
retaining  the  fradtured  bones.  But  all  who  are  ac- 
quainted with  the  fretful,  irritable  Itate,  in  which  pa- 
tients with  fractures  commonly  are,  and  with  the  pain 
that  tight  bandages  always  excite,  will  know,  that  al- 
though propofals  of  this  kind  may  appear  to  advant- 
age in  theoretical  difquifitions,  they  will  never  proba- 
bly be  of  real  utility.  And  accordingly  none  of  them 
have  ever  been  in  general  praftce. 

The  invention  of  the  late  Mr.  Gooch,  of  Norwich, 
is  the  one  that  promifed  to  prove  mod  ufeful  in  oblique 
fractures  of  the  thigh.  This'inftrument  is  delineated 
in  Plate  LXXXIII.  a^d  in  an  improved  date  by  the 
late  Dr.  John  Aiike%  in  Plate  LXXXIV. 


Sea.  XIIL  of  the  Patella.  361 

A  broad  firm  ftrap  of  leather,  lined  with  quilted 
cotton  or  fofc  flannel,  is  placed  on  the  upper  part  of 
the  limb,  where  it  is  firmly  fecured  with  buckles.  A 
fimilar  ilrap  is  put  round  the  under  part  of  the  thigh, 
and  made  to  rell  chiefly  on  the  condyles  of  the  femur. 
Two  or  three  fteel  fplints,  conne£lcd  with  the  (traps, 
pafs  from  one  to  the  other  in  fuch  a  manner,  that  by 
means  of  them  the  ftraps  can  be  forced  afundcr,  and 
retained  at.  any  dift:ance  during  the  cure. 

For  a  more  particular  account  of  this  apparatus,  the 
explanation  of  the  Plates  may  be  confulted. 

In  fome  cafes,  however,  the  pain,  fwelling,  and  In- 
flammation, are  fo  confiderablc,  as  to  preclude  the 
application  of  the  moft  fimple  bandage.  After  thefe 
fymptoms  are  relieved  by  local  bloodletting  and  other 
remedies,  Mr.  Gooch's  method,  or  Dr.  Aitken*s,  may 
be  adopted  where  the  fradured  bones  cannot  other- 
wife  be  retained  ;  if  not,  the  cure  mufl:  be  conducted 
in  the  ufual  way,  with  the  hazard  of  the  ends  of  the 
bone  palfing  each  other,  and  of  the  limb  being  fome- 
what  liiortened.  But  in  this  event,  under  the  circum- 
fl:ances  I  have  meniioncd,  although  the  patient  may 
regret  his  misfortune,  he  cannot  with  jufl:ice  blame 
the  furgeon. 


SECTION     XIII. 

Of  FraBitres  of  the  Patella. 

THE  patella  or  knee  pan  is  liable  to  fra£lures  from 
falls  and  bruifes  upon  the  knee.  Tranfverfe 
fradures  of  this  bone  are  mofl:  frequent :  we  alfo  meet 
with  longitudinal  fractures,  and  in  fome  cafes  it  is 
broken  into  three  or  four  different  pieces. 

In  fradures  of  the  patella,  we  are  defired  to  make 
a  guarded  progncfis  ;  for  by  mofl:  writers,  it  is  faid, 
that  they  almoft  conilantly  terminate  in  a  fliff  joint. 


362  Of  Fraaiiru         Chap.  XXXIX 

owing,  as  is  fuppofed,  to  the  callus  forming  in  too  great 
quantity,  and  finding  accefs  to  the  cavity  of  the  joint. 
I  have  not  found,  however,  that  fractures  of  this  bone 
are  fo  apt  to  produce  flifF  joints  as  we  are  led  to  ex- 
pe£l.  In  various  cafes  that  have  fallen  under  my 
care,  fcarcely  any  degree  of  ftifi'nefs  remained  after 
three  or  four  months  had  elapfed  ;  nor  is  it  probable, 
when  permanent  lamenefs  enfues  to  fraftures  of  this 
bone,  that  it  proceeds  from  fuperabundancy  of  callus. 
I  rather  think  that  it  proceeds  from  the  inflammation 
that  ufually  takes  place  ;  or  from  the  knee  being  kept 
too  long  in  an  extended  immoveable  pofture.  From 
a  dread  of  feparating  the  frattured  parts  of  the  bone 
before  they  are  firmly  united,  the  leg  is  ufually  pre- 
ferved  in  an  extended  pofture  for  eight,  or  perhaps 
ten  weeks  ;  a  much  longer  period  than  is  neceffary, 
and  by  which  alone  even  the  foundefl  joint  would  be 
apt  to  become  flilf  and  immoveable. 

In  the  treatment  of  fradlures  of  this  bone,  in  what- 
ever direction  they  may  run,  the  leg  jQiould  be  extend- 
ed, in  order  to  relax  the  only  mufcles  with  which  it 
is  connefted,  thofe  forming  the  ligament  inferted  into 
it.  With  this  view,  the  patient  fhould  be  placed  up- 
on a  bed  rendered  fo  firm  that  it  will  not  yield  during 
the  courfe  of  his  confinement ;  a  precaution  highly 
requifite  in  all  fractures  of  the  lower  extremities,  where 
long  confinement  to  bed  is  almoft  always  neceifary, 
and  where  unequal  finking  of  the  body  is  often  the 
fource  of  much  uneafinefs  to  the  patient,  and  may 
even  be  the  caufe  of  feparation  of  the  newly  replaced 
bones. 

This  being  done,  a  long  firm  fplint  of  timber,  thick- 
ly covered  with  foft  wool,  or  with  feveral  plies  of  fine 
flannel,  fliould  be  placed  beneath  the  thigh  and  leg, 
from  the  upper  part  of  the  one  to  the  extremity  of 
the  other  ;  and  to  this  the  limb  fhould  be  fecured  by 
two  ftraps  between  the  ankle  and  knee,  and  one  or 
two  between  the  knee  and  top  of  the  thigh.  This 
will  effedtually  preferve  the  leg  in  a  fi:ate  of  extenfion ; 


n 


Sea.  XIII.  of  the  Patella,  363 

and  it  does  it  in  the  eafiefl:  manner  when  the  fplint  is 
fufficiently  broad  and  properly  covered  with  flannel 
and  wool  in  the  manner  I  have  mentioned. 

The  different  parts  of  the  fractured  bone  are  now 
to  be  brought  as  near  together  as  pofTible  with  the 
hand  ;  but  no  bandage  is  yet  to  be  applied  to  them. 
Our  great  objed  at  firft  is  to  prevent  inflammation  ; 
for  which  purpofe  as  much  blood  fliould  be  taken 
from  the  joint  with  leeches  as  the  patient  can  proper- 
ly bear  ;  and  for  two  or  three  days,  or  as  long  as 
much  pain,  fwclling,  or  tenfion,  continue,  faturnine 
and  other  afliringent  applications  fliould  be  ufed  for 
renioving  them. 

This  being  accompliflied,  we  again  examine  the 
fl:ate  of  the  bone  ;  and  if  the  diflcrent  parts  of  it  are 
all  either  entirely  or  nearly  in  contaft,  they  ought  not 
to  be  difl:urbed.  The  joint  may  be  covered  with  a 
large  pledget  of  faturnine  cerate,  by  which  it  will  be 
kept  foft  and  eafy  ;  and  a  hooped  frame  fhould  be 
employed  to  fupport  the  bedclothes. 

But  if  the  different  parts  of  the  bone,  infl:ead  of 
being  nearly  in  contaft,  are  found  feparated  to  any 
confiderable  extent,  we  ought  flrfl:  to  replace  them, 
and  then  endeavour  to  retain  them  as  far  as  this  can 
be  done  with  bandages. 

In  longitudinal  fra<5lures  of  the  patella,  this  is  eafi- 
ly  done ;  for  in  this  direction  we  meet  with  no  refifl:- 
ance,  and  the  parts  are  eafily  retained  by  moderate 
prefl'ure,  either  with  the  common  uniting  bandage,  or 
with  flips  of  leather  fpread  with  glue  or  adhefive  plaf- 
ter.  But  in  tranfv^erfe  fraftures  of  this  bone,  as  that 
part  of  it  that  remains  connecled  with  the  extenfor 
mufcles  of  the  thigh  is  apt  to  be  drawn  forcibly  up- 
wards, we  cannot  always  replace  it  but  with  a  force 
that  would  excite  pain,  fwelling  and  inflammation. 

It  is  not  neceitary,  however,  that  the  diflcrent 
pieces  of  bone  be  kept  in  exadl  conta£l.  Where  it 
can  be  eafily  done,  it  ought  always  to  be  advifed  ;  but 
I  know  from  the  refult  of  ftveial  cafes  where  this  was 


2,64  Of  Fradures  Chap.  XXXIX. 

Impracllcable,  that  a  cure  may  be  obtained,  and  the 
joint  be  equally  firm  and  ufeful  as  it  was  before,  even 
although  the  Separated  portions  of  bone  cannot  be 
kept  within  an  inch  of  each  other.  We  fhould  not 
therefore  be  anxious  about  this  ;  and  inftead  of  ufing 
much  force  for  drawing  the  bones  into  contad,  no 
more  fhould  be  employed  than  the  patient  can  eafily 
bear. 

Various  bandages  have  been  invented  for  drawing 
the  divided  parts  of  a  fractured  knee  pan  together  ; 
but  alinoH:  all  of  them  have  been  formed  upon  erro- 
neous principles.  They  are  made  to  prefs  equally 
upon  the  upper  and  under  portion  of  the  bone  : 
whereas  the  leaft  reflection  on  the  anatomical  ftruc- 
ture  of  the  parts  mufl  render  it  obvious,  that  no  ad- 
vantage can  be  derived  from  much  prefTure  on  the 
inferior  part  of  the  bone,  which  always  remains  in  its 
natural  fituation  ;  and  therefore,  that  our  force  fhould 
be  entirely  applied  to  that  part  of  it  that  remains  con- 
nedled  with  the  ligament  of  the  extenfor  mufcles,  by 
the  adlion  of  which,  particularly  cf  the  re£lus  mufcle, 
this  portion  of  the  bone  is  drawn  upwards. 

In  Plate  LXXXVI.  a  bandage  is  reprefented,  from 
which,  while  it  fits  eafily  upon  the  parts  to  which  it 
is  applied,  every  advantage  may  be  derived  that  this 
kind  of  afliflance  can  give  :  it  confifls  of  two  circular 
(traps  of  firm  leather,  A  B,  lined  with  foft  flannel, 
with  two  perpendicular  flraps  C  E,  that  pafs  from  one 
end  to  the  other,  and  a  femilunar  firm  comprefs  G  j 
with  another  (trap  of  a  greater  length  D,  reaching 
from  the  point  of  the  toes  to  the  buckle  on  the  upper 
circular  flrap  round  the  thigh,  as  is  more  particularly 
reprefented  in  fig.  3.  of  the  fame  plate. 

The  leg  being  extended  and  raifed  to  a  proper 
height  for  relaxing  the  extenfor  mufcles  of  the  thigh, 
the  upper  edge  of  the  under  circular  flrap  A  fhould 
be  applied  to  the  under  part  of  the  inferior  portion  of 
the  bone,  fo  as  to  fupport  it  in  its  natural  fituation 
without  forcing  it  farther  up.      The  flrap  muft  be 


Sea.  XIII.  of  the  Patella.  365 

then  tightly  buckled  ;  and  the  upper  half  of  the  bone 
being  pulled  gently  though  firmly  down,  the  femilu- 
nar  comprefs  F  in  fig.  2.  mud  be  applied  round  the 
upper  end  of  it,  when  the  upper  circular  flrap  muft  be 
alfo  buckled.  By  means  of  the  two  perpendicular 
flraps  and  buckles,  we  now  make  a  gradual  firm  ex- 
tenfion,  which  will  not  move  the  under  circular  (trap 
if  it  was  previoufly  made  fufficiently  tight ;  but  which 
will  draw  the  other  down  if  it  has  not  been  made  too 
tight.  This  will,  in  fome  degree,  draw  down  the  up- 
per part  of  the  bone,  by  gently  pulling  the  femilunar 
comprefs  previoufly  applied  to  the  upper  part  of  it ; 
but  it  will  be  more  cffe6:iially  done  by  the  (trap  D 
made  fufRciently  tight  by  fixing  it  to  the  correfpond- 
ing  buckle  in  the  upper  circular  (trap  B. 

In  this  manner  the  diflerent  parts  of  the  bone  may 
be  made  to  approach  each  other  as  far  as  this  can 
with  propriety  be  done  ;  but  for  the  reafons  I  have 
given  already,  the  prelTure  fliouid  never  be  carried  fo 
far  as  to  endanger  the  excitement  of  pain,  inflamma- 
tion, or  fwelling. 

The  limb  being  fccurcd  in  the  manner  I  have  men- 
tioned, the  bandages  fliould  not  be  removed  till  the 
twelfth  or  fourteenth  day,  if  pain  and  inflammation 
do  not  render  a  more  early  removal  neceflary.  But 
about  this  period,  the  bandage  fliould  be  removed, 
when  the  limb  may  be  moderately  bent ;  ?.nd  this  be- 
ing cautioufly  repeated  every  fecond  or  third  day,  no 
interruption  will  be  given  to  the  cure,  while  the  mo- 
tion of  the  joint  will  be  preferved ;  which  it  feldoni 
or  never  is  when  this  piece  of  attention  is  omitted. 

The  joint  of  the  knee  is  liable  to  another  injury,  fo 
fimilar  in  its  effcfts,  as  well  as  in  the  method  of  cure, 
to  fractures  of  the  patella,  that  I  think  it  right  to  men- 
tion it ;  namely,  a  feparation,  by  external  violence,  of 
the  ligament  or  tendon  of  the  reftus  mufcle  from  the 
patella.  The  ufual  efiect  of  a  fmart  ilroke,  or  a  fe- 
vere  fall,  upon  the  forepart  of  the  knee,  is  a  frafture 
f>f  this  bone  j  but  where  a  perfon  carrying  a  heavy 


366  Of  Fraaures  of  the       Chap.  XXXIX, 

burden  upon  his  back,  fjills  with  his  knee  much  bent, 
a  rupture  of  the  tendon  more  frequently  happens  :  at 
leaft  I  have  met  with  it  in  feveral  inftances  from  this 
caufe,  in  which  the  tendon,  after  feparating  from  the 
bone,  retracted  to  the  diftance  of  two  or  three  inches. 
The  treatment  that  I  have  advifed  for  a  fradlure  of 
the  patella  proves  equally  fuccefsful  here  ;  only  it  will 
be  underltood,  that  in  this  cafe  no  advantage  can  be 
obtained  from  pulling  down  the  retracted  tendon  : 
for  not  being  connected  with  any  part  of  the  bone,  it 
cannot  be  laid  hold  of;  fo  that  we  have  to  truft  en- 
tirely to  the  extended  pofture  of  the  limb.  But  al- 
though the  tendon  and  bone  cannot  be  brought  clofe 
to  each  other,  yet  a  cure  may  always  be  accompliflied 
in  the  manner  I  have  mentioned. 


SECTION     XIV. 

Of  Fraaures  of  the  Bones  of  the  Leg. 

IN  fractures  of  the  leg,  only  one  bone  is  often  brok- 
en ;  but  a  frafture  of  both  is  more  frequent.  In 
this  cafe  the  feat,  as  well  as  the  direction  of  the  frac- 
ture, are  readily  perceived.  When  one  bone  only  is 
broken,  the  nature  of  the  injury  is  difcovered  with 
more  difficulty.  This,  however,  is  of  little  import- 
ance ;  for  v/hen  one  of  the  bones  remains  entire,  it 
ferves  fo  eli'eftually  to  fupport  the  other,  that  Httle 
more  is  neceffary  than  confinement  till  the  fractured 
bone  is  united. 

Fractures  are  more  frequent  near  the  joint  of  the 
ankle  than  in  other  parts.  A  great  proportion  indeed 
of  fractures  of  the  fibula  are  leated  an  inch  or  two 
above  the  under  extremity  of  this  bone,  this  being  the 
wreaked  part  of  it. 

The  fame  general  principles  that  I  have  propofed 
in  the  management  of  fractures  of  the  thigh  bone. 


Sed.  XIV.  Bones  of  the  Leg.  367 

prove  applicable  in  fra6lures  of  the  leg  :  in  replacing 
the  bones,  the  niufcles  of  the  limb  Ihould  be  relaxed  ; 
and  we  do  it  in  the  mod  effedual  manner  by  bending 
the  joint  of  the  knee,  and  flightly  extending  the  foot. 
The  leg  being  put  in  this  pofition,  the  bones  are  for 
the  mod  part  eafily  replaced  ;  and  with  no  more  ex- 
tenfion  than  can  be  eafily  given  by  one  alTiftant  at  the 
upper  end  of  the  limb,  and  another  at  the  ankle. 

This  being  done,  and  the  patient  placed  in  fuch  a 
manner  that  the  injured  leg  may  be  laid  upon  its  out- 
fide,  with  the  knee  bent,  the  fplints,  figs.  3.  5.  or  6. 
Plate  LXXXI.  fliould  be  applied  and  retained  with  the 
twelve  tailed  bandage  ;  the  fplint  on  the  outfide  of  the 
leg  reaching  from  a  little  above  the  knee  to  beneath 
the  ankle,  with  a  view  to  prevent  the  motion  of  eith- 
er of  thefe  joints,  by  which  the  bones  are  very  apt  to 
be  difplaced. 

Whether  the  fplints  are  of  firm  pafteboard,  or  fuch 
as  are  reprcfented  in  Plate  LXXXI.  they  would  for 
the  moft  part,  prove  fuiFicient :  but  when  the  patient 
is  either  refllefs,  or  troubled  with  fpafmodic  affections 
of  the  mufcles  of  his  leg,  an  additional  fplint  of  wood, 
fliaped  to  the  form  of  the  leg,  reprefented  in  figs.  i. 
and  2.  of  the  fame  plate,  fliould  be  appHed  along  the 
outfide  of  it ;  and  if  it  is  flightly  excavated  and  filled 
with  foft  wool  or  tow,  it  fits  with  eafe,  while  it  pre- 
vents, with  certainty,  the  ends  of  any  of  the  bones 
from  falling  down.  We  fix  it  with  ilraps  and  buc- 
kles, and  the  leg,  when  drefl'ed  in  this  manner,  has 
the  appearance  reprefented  in  Plate  LXXXV.  fig.  2. 

I  have  already  obfervcd,  that  after  the  drefTings  are 
applied,  the  leg  fliould  be  laid  upon  its  outfide,  with 
the  knee  bent,  and  the  foot  fupported  with  a  turn  of 
a  roller,  as  reprefented  in  the  figure  jufl  mentioned. 
The  intention  of  this  is  to  relax  the  mufcles  of  the 
limb  ;  by  which  the  patient  lies  with  more  eafe,  while 
the  bones  are  lefs  liable  to  be  difplaced,  than  where 
tJie  mufcles  are  fully  flretched  out,  as  till  lately  was 
ahnoft  the  univerfal  cuftom. 


358  Of  Fradures  cfthe       Chap.  XXXIX 

But  although  the  leg  (hould  be  placed  in  fuch  a 
pofture  as  may  tend  molt  clTeclually  to  relax  the  muf- 
cles ;  yet  the  knee  fhould  not  be  more  bent  than  this 
requires :  for  when  this  joint  is  kept  long  much  bent, 
it  proves  almoft  equally  irkfome  to  the  patient  as 
when  the  leg  is  fully  llretched  out.  The  knee  fhould 
not  therefore  be  more  bent,  nor  fliould  the  patient  be 
laid  more  towards  his  fide,  than  is  juft  neccflary  for 
allowing  the  leg  to  be  placed  upon  its  outfide. 

Some  people,  however,  cannot  fleep  when  lying  on 
either  fide ;  and  fome  practitioners  think,  that  frac- 
tures of  the  leg  heal  more  eafily  when  the  patient  is 
laid  on  his  back,  and  the  limb  placed  upon  the  gaf- 
trocnemii  mufcles,  with  the  toes  upwards.  In  fuch 
cafes  the  patient  may  be  placed  upon  his  back,  and 
yet  the  curved  pofition  of  the  leg  retained.  This  may 
be  done  in  difterent  ways  ;  but  the  eafieft  method  is, 
to  raife  the  leg,  and  fupport  it  upon  a  frame,  at  a 
proper  height  above  the  level  of  the  body.  This  ad- 
mits of  the  limb  being  placed  in  the  pofture  I  have 
advifed,  and  with  any  necefl'ary  degree  of  curvature. 

Even  where  a  fractured  leg  is  placed  on  the  out- 
fide, it  proves  to  be  a  pleafant  variety  to  have  the  pof- 
ture altered ;  and  with  fuch  a  frame  it  can  be  eafily 
done. 

A  limb  placed  in  this  fituation  is  reprefented  in 
Plate  XCV.  fig.  2,  and  the  fame  variety  of  pofture  is 
admiflible  in  fradtures  of  the  thigh.  The  patient  may 
from  the  firfl  be  placed  with  his  leg  curve'd  in  this 
manner ;  or  he  may  afterwards  turn  upon  his  back, 
and  the  cure  be  completed  while  he  remains  in  this 
pofture,  or  he  may  alternately  change  from  one  to  the 
other.  The  inconveniency  ufually  complained  of, 
from  the  leg  refting*  upon  the  heel  when  ftretched 
out,  is  avoided  by  an  excavation  or  opening  in  the 
bottom  of  the  frame  foF  receiving  the  heel,  or  it  may 
be  done  by  allowing  the  heel  to  project  over  the  edge 
of  the  frame  altogether.  No  change  of  pofture,  how- 
ever, fhould  be  permitted  for  the  firft  ten  or  twelve 


Se6l.  XIV.  Bones  of  the  Leg,  369 

days.  About  this  time  the  patient  may  be  turned  with 
caution  upon  his  back,  and  the  leg  moved  from  one 
pofition  to  the  other,  CiU'e  being  taken  to  preferve  it  in 
the  fame  degree  of  curvature. 

In  fradures  of  the  leg,  where  the  fibula  only  is  In- 
jured, it  is  apt  to  pafs  unnoticed,  and  to  be  confider- 
ed  as  a  fprain  of  fome  of  the  niufcles  :  but  as  very 
ferious  confequences  are  apt  to  eiilue  from  this  mif- 
take,  it  ought  to  be  flriclly  guarded  agalnft. 

When  treating  of  fradures  of  the  clavicle,  I  had 
occafion  to  mention  an  appearance  which,  of  itfelf,  is 
extremely  fimple  and  of  eafy  treatment ;  but  which, 
from  want  of  attention  to  the  caufe  of  it,  has  often 
been  produ6lIve  of  much  perplexity  both  to  patient 
and  praditioners  ;  I  mean  what  is  commonly  termed 
the  rifing  end  of  a  bone  ;  and  as  this  frequently  oc- 
curs in  the  leg,  I  think  it  proper  to  mention  it  here. 

When  the  bones  of  the  leg  are  broken  diredly 
acrofs,  they  fomctlmes  ferve  to  fupport  each  other  fo 
efFeftually  that  neither  of  them  are  difplaced.  In  fuch 
circumflances,  no  inequality  appears  in  the  limb,  if  it 
be  not  from  fome  temporary  fwelling  of  the  foft  parts. 
But  when  both  bones  are  not  only  fradlured  but  dif- 
placed, the  under  part  of  them,  or  that  portion  con- 
nected with  the  foot,  is  almofl  always  drawn  down, 
and  towards  the  back  part  of  the  leg  ;  by  which  an 
unequal  prominency  is  produced  by  the  projeding  end 
of  the  upper  portion  of  bone,  or  that  part  of  it  which 
ftill  remains  conneded  with  the  knee. 

It  is  this  that  is  termed  the  rifing  end  of  the  bone  ; 
and  in  reducing  fuch  fraftures,  much  pains  is  com- 
monly taken  to  force  this  part  of  the  bone  into  con- 
tad  with  the  other.  It  is  obvious,  however,  that  the 
upper  part  of  the  bone  does  not  rife,  but  that  the  in- 
ferior portion  falls,  or  is  drawn  down,  and  out  of  its 
natural  fituation,  by  the  weight  of  the  foot,  as  well  as 
by  the  contraction  of  the  mufcles  on  the  back  part  of 
the  leg  :  hence  no  advantage  can  be  gained  by  any 

Vol.  III.  A  a 


370  Foot  and  Tecs.         Chap.  XXXIX. 

preflurc  made  upon  the  fuperior  part  of  the  bone, 
while  much  harm  is  often  done  by  it,  by  bandages 
being  fo  tightly  tied  over  it  as  to  cut  all  the  teguments 
with  which  it  is  covered ;  and  thus  forming  a  com- 
pound fracture  of  what  othervvife  would  have  remain- 
ed of  the  moft  fmiple  kind. 

The  upper  part  of  the  bone  never  rifes  out  of  its 
natural  fituation  ;  fo  that  any  inequality  in  the  form 
and  appearance  of  the  leg,  muft  be  produced  in  the 
manner  I  have  mentioned,  namely,  by  the  inferior  por- 
tion of  the  bones  being  drawn  out  of  the  fituation 
which  they  ought  to  occupy  :  fo  that  inftead  of  forc- 
ing down  the  upper  part  of  the  bone,  our  fole  objefb 
fhould  be  to  raife  the  inferior  part  of  it,  fo  as  to  bring 
them  into  contact ;  and  by  fupporting  it  in  this  fitu- 
ation, to  endeavour  with  as  much  certainty  as  pofli- 
ble  to  effect  their  reunion.  In  this  manner  a  cure 
may  be  often  accomplifhed,  which  could  not  be  ob- 
tained in  any  other  way. 


SECTION     XV. 

Gf  FraBures  of  the  Bones  of  the  Foot  and  Toes. 

FRACTURES  of  the  bones  of  the  foot  and  toes 
are  to  be  managed  nearly  in  the  fame  manner 
with  fimilar  injuries  ^f  the  hands  and  fingers.  All 
portions  of  difplaced  bone  muft  be  put  into  its  natural 
fituation  with  as  much  accuracy  as  pollible  ;  and  we 
endeavour  to  retain  them  by  fplints  fitted  to  the  form 
of  the  part,  fupported  with  different  turns  of  a  roller. 
In  fradtures  of  the  bones  of  the  foot,  a  large  fplint 
ftiould  be  applied  over  the  fole,  fo  as  to  fupport  the 
whole  of  it ;  and  no  freedom  fhould  be  permitted  in 
the  motion  either  of  the  foot  or  ankle  during  the  cure ; 
for  nothing  tends  more  to  difplace  a  fradured  portion 
of  bone  than  the  adion  of  the  contiguous  mufcles." 


Sed.  XVT.         Of  Compound  Fraclures,  371 

SECTION  XVI. 

Of  Compound  Fra&urcs. 

S  the  term  compound  fra6lure  has  been  applied 
to  injuries  of  different  kinds,  I  think  it  right  to 
define  with  precifion  the  meaning  that  I  wifh  to  affix 
to  it.  A  fraclure  of  a  bone,  communicating  with  an 
external  opening  or  wound  in  the  corrcfponding  tegu- 
ments, I  denominate  a  compound  fraclure.  It  is  not 
the  circumftance  of  a  fractured  bone  being  accompa- 
nied with  a  wound  in  the  contiguous  foft  parts,  that 
conftitutes  a  compound  frafture  :  this  may  happen 
with  a  frafture  of  the  moft  fimple  nature,  tjnlefs  the 
external  opening  communicates  with  the  fraclure  of 
the  bone,  the  fradlure  is  not  affecled  by  it,  even  al- 
though the  wound  is  extenfive  ;  while  the  fmalleft 
punclure  pafTmg  dire6lly  to  the  fubftance  of  a  fraftur- 
ed  bone,  adds  difficulty  to  the  method  of  cure,  and 
hazard  to  the  event. 

Compound  fradures  are  produced,  not  only  by  ex- 
ternal violence,  but  frequently  by  the  bones  in  fmiple 
fradtures  being,  in  the  courfe  of  the  cure,  pufhed 
through  the  corrcfponding  teguments.  In  fome  cafes, 
this  happens  from  a  bone  being  fo  very  obliquely 
fradlured  that  it  terminates  in  a  (harp  point ;  while  in 
others  it  is  the  evident  effeft  of  too  tight  a  bandage, 
applied  with  the  view,  as  we  have  feen  in  Seft.  XIV. 
of  bearing  down  the  upper  end  of  the  fradlured  bone. 
But  in  whatever  way  a  compound  fra£lure  is  produ- 
ced, the  confequences  that  refult  from  it  are  nearly 
fimilar.  The  admiffion  of  air  to  a  fra6lure  adds  evi- 
dently to  the  rilk  that  attends  it ;  and  whether  this 
takes  place  as  an  immediate  effedl  of  external  violence, 
or  as  the  confequence  of  preffure  upon  the  ends  of 
the  bone,  no  difference  is  perceived  in  the  effeds  that 
refult  from  it. 

A  A  2 


T^yi  Of  Compound  Fradures.     Chap.  XXXIX. 

Various  reafons  might  be  adduced  to  prove  that  it 
is  the  admiflion  of  air  alone  that  renders  compound 
fra£lures  more  hazardous  than  others.  I  may  fhortly 
mention,  however,  one  of  the  mofl  obvious  proofs  of 
it.  The  worfl  variety  of  fimple  fradlure,  where  the 
bone  is  broken  in  the  mofl  obhque  manner,  and  where 
it  is  difficult  or  perhaps  impoflible  to  retain  it  in  its 
fituation,  will  continue  to  do  well,  and  to  excite  no 
fevere  fymptoms,  as  long  as  the  fkin  remains  entire  : 
but  if,  by  any  accident,  the  point  of  the  bone  is  pufh- 
ed  through  the  teguments,  from  that  moment  the  pain 
becomes  more  fevere  ;  the  inflammation,  which  be- 
fore perhaps  was  trifling,  becomes  now  confiderable  ; 
fever  takes  place  ;  the  limb  is  apt  to  be  attacked  with 
fevere  fpafmodic  twitchings  ;  and  to  thefe  gangrene 
or  extenfive  fuppurations  frequently  fucceed. 

In  the  treatment  of  compound  fradures,  our  firft 
obje£t  is  to  reftrain  profufe  hemorrhagies  when  they 
take  place,  by  a  proper  application  of  the  tourniquet : 
our  next  is  to  confider,  whether  we  fhould  attempt  to 
fave  the  limb,  or  recommend  immediate  amputation. 

From  the  difficult  treatment  and  uncertain  event  of 
compound  fractures,  practitioners  have  been  very  uni- 
verfally  difpofed  to  confider  the  amputation  of  the 
fradured  limb  as  necefi'ary.  At  all  times  indeed  in- 
dividuals have  oppofed  this  general  opinion.  Among 
others,  Mr.  Bilguer  of  Berlin  wrote  decidedly  againft 
it ;  and  he  afferts,  that  amputation  is  feldom  or  never 
neceflTary,  and  that  a  greater  number  of  patients  would 
recover  if  this  operation  were  entirely  exploded. 

To  me  it  appears  that  both  opinions  are  in  the  ex- 
treme ;  and  that  they  have  been  formed  without  that 
attention  to  the  difcrimination  of  circumjflances  which 
the  great  importance  of  the  queflion  merits. 

In  private  praftice,  where  patients  can  be  kept  qui- 
et and  perfectly  at  reft  from  the  date  of  the  injury, 
and  where  due  attention  can  be  enfured  on  the  part 
of  the  practitioner,  as  well  as  of  experienced  nurfes, 
compound  fractures  fhould  receive  a  different  treat- 


Sed.  XVI.         Of  Compound  Fra&iires,  373 

ment  from  thofe  that  happen  in  a  field  of  battle  or  in 
an  engagement  at  fea.  So  many  inftances  occur,  in 
which,  from  amputation  being  objefted  to  by  the  pa- 
tient, from  the  Hmb  being  too  much  fwelled  or  in- 
flamed before  affiftance  is  called,  or  from  intention  on 
the  part, of  the  pra£titioner  to  endeavour  to  fave  the 
limb,  of  cures  being  made,  that  I  am  now  convinced 
that  in  private  praftice  immediate  amputation  Ihould 
never  be  advifed,  unlefs  when  the  bones  are  fo  much 
fhattered  that  they  cannot  reunite  ;  or  where,  from 
the  violence  of  the  injury,  the  texture  of  the  foft  parts 
is  completely  deftroyed. 

On  the  other  hand,  I  believe,  that  it  would  be  a 
good  general  rule,  both  in  the  navy  and  army,  to  am- 
putate immediately  in  all  cafes  of  compound  fradlure 
that  occur  in  battle,  where  the  accident  is  either  in  the 
humerus  or  thigh,  or  where  both  bones  of  the  fore- 
arm or  leg  are  fradlured.  In  this  fituation,  the  pa- 
tient is  expofed  to  a  variety  of  hardfliips  that  tend  to 
aggravate  his  danger ;  while  no  accommodation  can 
be  procured  nor  attention  given  to  lelfen  it. 

In  oppofition  to  this  it  may  be  alleged,  that  com- 
pound fradures  are  frequently  cured  in  military  hof- 
pitals.  This  indeed  is  the  argument  on  which  Mr. 
Bilguer  refts  his  opinion :  but,  like  every  prejudiced 
inquirer,  he  ftates  it  partially. 

I  readily  admit,  as  every  one  accuftomed  to  the 
treatment  of  fractures  will  do,  that  cures  are  fome- 
times  unexpedledly  accompliflied  under  the  mofl  un- 
toward circumftances  ;  but  the  favourable  termina- 
tion of  a  few  cafes  will  never  invalidate  an  eftablifhed 
pradice,  founded  on  the  fure  bafis  of  experience  and 
obfervation. 

When  an  officer  of  rank  and  fortune  receives  a 
compound  fradure,  and  where  circumftances  admit  of 
his  being  foon  conveyed  to  good  quarters,  with  a  prof- 
pe£t  of  this  being  his  place  of  refidence  during  the 
cure,  the  cafe  muft  be  bad  indeed  if  we  do  not  at- 
tempt to  fave  the  limb.     But  this  does  not  happen  in 


374  Of  Compound  Fraditrcs.     Chap.  XXXIX. 

the  ufual  routine  of  military  practice  ;  and  I  mention 
fuch  cafes  only,  becaufe  the  accounts  we  have  receiv- 
ed of  Mr.  Bilguer's  fuccefs,  are  .chiefly  if  not  entirely 
drawn  from  fuch  inftances ;  and  they  therefore  afford 
no  general  conclufion  relative  to  military  and  naval 
pradice. 

Even  in  private  practice,  I  am  far  from  thinldng 
that  our  attempts  to  fave  fractured  limbs  will  always 
fucceed.  I  know  that  they  do  not ;  and  in  the  courfe 
of  much  bufmefs,  cafes  fometimes  occur  in  which  the 
beft  conducted  meafures  fail,  particularly  where  the 
large  joints  are  injured,  and  where  the  long  bones  are 
not  only  fractured  but  fplintered  in  different  places  : 
but  I  alfo  know  from  experience,  that  where  at  lafl 
we  are  obliged  to  advife  amputation,  more  recover 
when  the  operation  is  delayed,  than  commonly  do 
where  it  is  performed  foon  after  the  accident ;  at  lead 
this  has  been  very  commonly  the  cafe  in  the  courfe  of 
my  obfervation.  Of  thofe  who  have  died  foon  after 
the  operation,  either  from  the  fever  induced  by  the 
extenfive  wound  ;  from  the  great  and  fudden  change 
produced  in  the  circulating  fyftem  by  the  removal  of 
a  limb ;  or  from  the  perturbation  and  violent  agita- 
tion of  fpirits  which  the  unexpected  lofs  of  a  limb 
muft  always  induce,  a  great  proportion  has  been  of 
thofe  on  whom  the  operation  was  performed  immedi- 
ately after  the  accident :  a  patient  in  this  ftate  of  bo- 
dy and  mind  muft  be  ill  fitted  for  undergoing  the  fe- 
verity  of  fuch  an  important  operation  ;  and  accord- 
ingly all  the  caufes  that  I  have  enumerated  concur  to 
render  the  fubfequent  fever,  and  every  concomitant 
fymptom,  more  violent  than  we  commonly  find  them 
in  patients  who  have  been  reduced  by  confinement 
and  a  low  regimen,  and  who,  from  having  full  leifure 
to  reflect  upon  the  danger  of  their  fituation,  are,  from 
their  own  conviction  of  the  neceffity  of  the  meafure, 
very  readily  induced  to  fubmit  to  the  operation. 

A  patient  may  indeed  be  brought  fo  low  as  to  make 
the  fuccefs  of  the  operation  doubtful  from  this  caufe 


Se6l.  XVL         Of  Compound  Fraffures.  375 

alone  :  but  a  practitioner  may  always  guard  againfl: 
this,  by  propofmg  the  operation  as  foon  as  his  attempts 
to  fave  the  limb  prove  alDortive,  and  before  the  patient's 
ftrength  has  declined  too  much. 

Amputation  feems  to  prove  more  fuccefsful  in  the 
more  advanced  ftages  of  compound  fradlures  than  im- 
mediately after  the  accident ;  and  ftill  more  fo  in  the 
advanced  ftages  of  chronic  affedlions,  particularly  in 
white  fwellings  of  the  joints,  as  I  have  elfewhere  re- 
marked, than  in  the  more  early  periods  of  the  difeafe. 
A  point  of  the  greateft  practical  importance  is  thus  of- 
fered to  our  confideration.  So  far  as  my  obfervation 
goes,  I  confider  the  fact  as  afcertained  ;  and  if  the  ex- 
perience of  others  leads  to  the  fame  conclufion,  it  will 
prove  the  moft  convincing  argument  againft  early  am- 
putation. In  the  courfe  of  my  own  experience,  I  do 
not  recoiled  an  inftanae  of  death  having  enfued  from 
the  operation  alone,  where  the  difeafe  was  of  fome  du- 
ration for  which  it  was  advifed  ;  and  it  has  often  been 
performed  where  the  patient  was  greatly  exhaufted  : 
whereas  many  have  died  merely  from  the  operation, 
where  it  has  been  put  in  practice  foon  after  the  acci- 
dent. AVhen  I  fpeak  of  death  as  the  confequence  of 
the  operation,  I  do  not  mean  fuch  inftances  of  it  as 
occur  from  hemorrhagies  breaking  out  in  the  courfe 
of  a  fhort  time  after  the  patient  is  laid  in  bed,  as  thefe 
commonly  happen  from  negligence  on  the  part  of  the 
furgeon,  at  whatever  period  a  limb  may  be  amputated  ; 
but  fuch  as  take  place  about  the  fecond  or  third  day, 
and  in  fome  inftances  at  a  later  period,  from  the  vio- 
lence of  the  fever  induced  by  and  commencing  foon 
after  the  operation. 

When  amputation  is  not  performed  immediately, 
or  foon  after  the  injury  is  received,  all  praditioners 
agree  that  it  cannot,  for  feveral  days  at  leaft,  and  oft- 
en for  a  much  longer  period,  be  admiftible.  Differ- 
ent caufes  may  afterwards  render  it  neceflary. 

1.  Hemorrhagies  under  certain  circumftances. 

2.  Extenfive  mortification. 


37^  Of  Compound  Fra6lures,     Chap.  XXXIX. 

3.  The  ends  of  the  fractured  bones  remaining  long 
difunited,  while  a  copious  difcharge  of  matter  endan- 
gers the  ftrength  of  the  patient. 

When  hemorrhagies  take  place  immediately,  we 
have  it  always  in  our  power  to  command  them,  either 
by  comprefTion  alone,  or  by  enlarging  the  wound  when 
it  is  too  fmall,  and  fecuring  the  bleeding  arteries  with 
ligatures.  Sometimes,  however,  when  no  difcharge 
of  importance  occurs  at  firft,  profufe  hemorrhagies 
will  take  place  at  the  end  of  feveral  days.  It  may  be 
difficult  in  fome  cafes  to  account  for  this  ;  but  we  cart 
frequently  trace  it  to  the  effect  of  friction  ;  the  coats 
of  an  artery  being  deftroyed  by  beating  or  rubbing 
upon  the  Iharp  edge  of  a  fplintered  bone. 

Even  in  this  advanced  ftate  of  the  injury,  we  may 
frequently  be  able  to  fecure  the  wounded  arteries  with 
ligatures.  But  the  limb  is  fometimes  fo  much  fwelled 
and  inflamed  before  the  hemorrhagy  appears,  that  the 
original  opening  will  not  admit  of  this  ;  and  on  pro-^ 
ceeding  to  enlarge  it,  fuch  confufion  is  met  with  from 
effufed  coagulated  blood  between  the  interftices  of  the 
mufcles,  as  well  as  through  the  whole  cellular  mem- 
brane of  the  affected  parts,  that  the  divided  arteries 
cannot  be  all  brought  into  view,  but  by  fuch  extenfive 
incifions  as  in  this  (late  of  the  parts  would  create  more 
hazard  than  amputating  the  limb  at  a  proper  dillance 
above  :  and  although  it  is  not  frequent,  yet  inllances 
happen,  where  the  mofl  expert  furgeons  are  obliged 
in  this  fituation  to  amputate. 

Mortification  is  perhaps  the  moft  urgent  motive  for 
amputating  in  this  ftage  of  compound  fradtures.  I 
{hall  have  occafion,  however,  to  confider  this  fubjedt 
more  particularly  in  the  chapter  on  amputation  ;  and 
with  refpect  to  the  third  caufe  that  I  have  mentioned, 
no  reunion  taking  place  between  the  fractured  parts 
of  the  bone,  and  a  finking  of  the  patient's  ftrength 
from  too  copious  a  difcharge  of  matter,  no  practition- 
er of  experience  will,  in  this  fituation,  difpute  the  pro* 
priety  of  amputation. 


Sea.  XVI.       Of  Compound  FraBures.  377 

It  is  this  ftate  of  a  compound  fradlure,  when  the 
original  inflammatory  fever  excited  by  the  injury  is 
gone,  and  before  the  patient  is  too  much  weakened 
by  the  difcharge,  which  of  all  others  I  confider  as  the 
mod  favourable  for  amputation.  The  exad  time  can- 
not poiTibly  be  fixed  by  any  general  obfervation :  it 
muft  depend  upon  the  particular  circumftances  of  ev- 
ery cafe,  and  chiefly  upon  the  quantity  of  the  difcharge, 
and  ftrength  of  the  patient ;  and  thefe  again  are  points 
which  the  judgment  of  the  practitioner  in  attendance 
can  alone  decide  upon.  I  may  remark,  however,  that, 
as  long  as  the  patient  does  not  feem  to  be  much  hurt 
by  the  difcharge,  however  great  it  may  be,  the  opera- 
tion fhould  not  be  advifed  ;  for,  while  his  ftrength  is 
not  much  impaired,  v/e  may  with  fafety  proceed  in  our 
endeavours  to  fave  the  limb. 

From  what  has  been  faid,  it  will  appear,  that  in  pri- 
vate pra6lice,  very  few  cafes  can  occur  of  compound 
fradlures,  in  which  we  fhould  not  attempt  to  fave  the 
limbs. 

In  the  treatment  of  compound  fra£tures,  our  objeft 
is  the  fame  as  in  the  management  of  thofe  of  the  mofl 
fmiple  nature  ;  namely,  to  replace  the  bones  that  may 
be  deranged,  and  to  retain  them  till  they  are  united. 

In  the  hrft  place,  all  extraneous  bodies  fhould  be 
removed,  as  well  as  all  thofe  fmall  pieces  of  bone  that 
will  not  probably  unite  with  the  reft  ;  for  which  pur- 
pofe,  the  opening,  if  too  fmall  to  admit  of  their  being 
eafily  taken  out,  fhould  be  enlarged  with  a  fcalpel. 
And  this  being  done,  we  in  general  find^  that  the 
bones  are  eafily  replaced  by  relaxing  all  the  muicles 
of  the  limb  in  the  manner  already  pointed  out  in  the 
preceding  fcdions  of  this  chapter.  Only  one  excep- 
tion occurs  to  this  :  a  fharp  point  of  a  bone  is,  in  feme 
inftances,  fo  far  puflicd  through  the  teguments,  that  it 
cannot  be  replaced  by  an  ordinary  fcice  ;  ?nd  to  a 
certain  extent,  the  greater  the  force  is  that  we  apply, 
the  more  firmlv  the  protruded  portion  of  bene  is  fixed 
between  the  fkin  and  parts  beneath.     In  tliis  fituation. 


378  Of  Compound  Fradures,     Chap.  XXXIX. 

we  fhould  either  faw  off  the  end  of  the  protruded  por- 
tion of  bone,  or  enlarge  the  wound. 

When  a  long  fliarp  point  of  bone  is  much  protru- 
ded, we  fhould  not  hefitate  to  remove  it ;  for,  although 
it  might  be  reduced,  it  would  not  readily  unite  with 
the  refl  of  the  bone,  at  the  fame  time  that  it  would  be 
apt  to  excite  much  pain  and  irritation.  When  the 
portion  to  be  taken  away  is  fmall,  it  may  be  done  with 
the  cutting  forceps  ufually  employed  in  amputations  : 
but,  when  it  cannot  be  eafily  done  in  this  manner,  it 
may  with  fafety  be  taken  off  with  a  faw  ;  a  piece  of 
pafleboard,  or  thin  fheet  lead  being  previouHy  inf«rt- 
cd  between  it  and  the  teguments  beneath. 

But  when  the  protruded  portion  of  bone  is  broad 
at  the  bafe,  and  not  of  great  length,  as  there  will  be 
caufe  to  hope  that  it  may  unite  with  the  reft  of  the 
bone  if  the  correfponding  parts  are  brought  in  conta£t, 
we  ought  certainly  to  endeavour  to  fave  it ;  and  in 
general  we  are  able  to  do  fo  by  enlarging  the  opening 
through  which  it  has  paffed.  If  we  take  care  to  avoid 
any  large  blood  veffels  and  nerves,  which  thofe  ac- 
quainted with  the  anatomy  of  the  pares  will  readily 
do,  no  danger  will  occur  from  the  operation.  Inftead 
of  increaling  the  danger  of  the  patient,  it  tends  often 
to  leffen  it,  by  removing  a  powerful  caufe  of  pain  and 
irritation,  and  thus  preventing  that  inflammatory  ten- 
lion  to  which  limbs  in  this  fituation  are  particularly 
liable. 

To  thofe  not  accuftomed  to  manage  compound 
fradiures  in  this  manner,  the  praftice  that  I  now  recom- 
mend may  be  fuppofed  to  be  attended  with  hazard  ; 
and  to  convert  a  fmall  puncture  into  an  extenfive 
wound,  may  often  appear  to  be  cruel  and  unneceffa- 
ry.  But  as  the  admiffion  of  air  has  already  occafion- 
ed  all  the  mifchief  that  can  arife  from  this,  we  do  not . 
in  this  manner  add  to  the  hazard  of  the  patient ;  and 
it -is  generally  \yq\\  known,  that  a  free  incifed  wound 
heals  more  readily  than  a  fmall  pun6lure.  It  is  the 
Ikin  only  that  for  the  moft  part  we  have  to  cut  here  j 


SecV.  XVI.       Of  Compound  Fra6lures,  379 

but  even  where  the  bone  cannot  be  eafily  reduced 
without  carrying  the  incifion  into  the  fubflance  of  the 
contiguous  mufcles,  we  fhould  not  hefitate  to  advife 
it :  only,  in  this  cafe,  the  opening  fliould  be  made  as 
much  as  poffible  in  the  direction  of  the  fibres  of  the 
mufcles. 

The  fplinters  of  bone,  coagulated  blood,  and  other 
extraneous  bodies  being  removed,  any  artery  that  may 
be  cut  being  fecured  with  a  ligature,  and  the  protru- 
ded portion  of  bone  replaced,  the  frafture  is,  in  other 
refpedis,  to  be  reduced  in  the  manner  I  have  advifed 
when  fpeaking  of  fimple  fractures  ;  that  is,  by  relax- 
hig  the  mufcles  of  the  limb,  and  extending  the  bones 
no  more  than  is  juft  neceflary.  This  being  done,  a 
pledget  of  foft  lint,  fpread  with  any  emollient  oint- 
ment, fhould  be  laid  over  the  wound,  when  the  limb 
fhould  be  placed  upon  a  firm  fphnt,  and  flill  kept  in 
a  relaxed  polture.  As  it  is  of  much  importance  that 
the  wound  be  regularly  drelfed  without  moving  the 
limb,  it  fhould,  if  poilible,  be  fo  placed,  that  this  can 
be  done  ;  and  with  the  fame  view,  the  twelve  tailed 
bandage,  in  compound  fractures  of  the  extremities, 
fliould  be  preferred  to  the  roller. 

As  it  is  a  point  of  the  utinofl  importance  to  place 
the  limb  in  fuch  a  pofhire  as  will  admit  of  the  fore 
being  dreffed  without  being  moved,  various  inventions 
have  been  propofed  for  rendering  this  in  every  cafe 
practicable.  Few  of  thefe,  however,  have  anfwered 
the  purpofe  for  which  they  were  intended.  The  beft 
that  I  have  feen  is  a  box  invented  by  the  late  ingenious 
Mr.  James  Rae  of  this  place  ;  of  which,  with  fome 
improvements  made  by  his  fon  Mr.  John  Rae,  I  now 
give  a  delineation.  The  leg  may  be  laid  in  it  either 
l")ent  or  flraight,  and  a  wound,  wherever  fituated,  may 
be  dreffed  without  altering  the  pofition  of  the  limb, 
as  will  be  more  clearly  underflood  from  the  reprcfen- 
tation  of  the  inft rumcnt,  Plate  LXXXIV.  fig.  3. 

In  whatever  fituation  the  limb  is  placed,  it  is  an  ob- 
ject of  the  firft  importance  to  endeavour  to  prevent 


380  Of  Compound  Fraaures.     Chap.  XXXIX. 

inflammation  ;  for,  when  mortification  enfues,  it  may- 
be ahnoft  always  traced  to  a  high  degree  of  inflam- 
mation ;  and  to  this  alfo  may  be  traced  thofe  exten- 
five  colledlions  of  matter  which  often  occur  in  com- 
pound fra6lures.  We  are,  therefore,  from  the  firfl, 
to  guard  againlt  the  acceflion  of  this  fymptom  ;  by 
one  or  more  general  bloodlettings,  proportioned  to  the 
flrength  of  the  patient ;  by  the  application  of  leeches 
to  the  edges  of  the  fore  ;  by  the  ufe  of  opiates ;  by 
gentle  laxatives  ;  a  low  regimen  ;  and  other  parts  of 
an  antiphlogiftic  courfe.  The  dreflings  fliould  be  re- 
moved once  or  twice  daily,  according  to  the  quantity 
of  matter ;  and  inftead  of  dry  lint,  pledgets  of  any 
emollient  ointment,  or  Goulard's  cerate,  fliould  be 
preferred  ;  for  I  have  not  found  in  any  ftate  of  thefe 
fores  that  ointments  do  harm  ;  and  they  always  fit  ea- 
fily,  and  are  more  eafily  removed  than  when  dry  lint 
is  applied  alone. 

Warm  emollient  poultices  are  commonly  applied 
at  firfl;,  and  continued  for  a  good  many  days ;  but  as 
they  prove  always  troublefome,  and  cannot  be  remov- 
ed without  in  fome  degree  altering  the  pofl:ure  of  the 
limb,  I  think  it  better  to  avoid  them  till  we  fee  wheth- 
er or  not  they  become  neceflary  by  the  approach  of 
inflammation.  In  that  event,  they  fhould  be  immedi- 
ately employed  as  the  furefl:  means  of  exciting  a  dif- 
charge  of  matter  :  for,  although  we  would  rather  wifli 
the  fore  to  heal  by  what  is  termed  the  firfl:  intention, 
without  the  formation  of  matter  ;  yet  this  being  a  rare 
occurrence  in  wounds  attending  compound  fraftures, 
and  a  plentiful  difcharge  of  good  pus  being  the  mofl: 
certain  preventive  of  mortification,  we  fliould  not  he- 
jfitate  in  our  endeavours  to  promote  it  whenever  the 
inflammation  becomes  fevere. 

As  foon,  however,  as  our  views  are  accompliflied, 
by  the  inflammation  fubfiding,  and  a  free  difcharge  of 
matter  having  taken  place,  the  poultices  fliould  be  laid 
afide  :  for  when  too  long  continued,  they  certainly  do 


Se£l.  XVI.       Of  Compound  Fra&ures.  381 

harm,  by  relaxing  the  parts  too  much,  and  exciting 
too  profufe  a  difcharge. 

When  matter  is  difcharged  from  compound  frac- 
tures in  too  great  abundance,  befides  laying  afide  the 
ufe  of  emollient  poultices,  the  fore  fhould  be  dreifed 
with  aftringents,  fuch  as  foft  lint  dipped  in  a  folution 
of  faccharum  faturni,  with  a  due  proportion  of  bran- 
dy ;  and  the  patient  fhould  be  fupported  with  nour- 
ifhing  food,  a  free  ufe  of  wine,  Peruvian  bark,  and 
elixir  of  vitriol.  A  free  vent  fnould  be  procured  for 
the  matter ;  and  when  this  cannot  be  obtained  by  the 
pofture  of  the  limb,  it  fhould  be  done  by  making  a 
counter  opening  in  a  more  depending  part.  The  ne- 
celFity,  however,  of  this,  may  be  often  prevented  by 
employing  foft  lint,  or  covering  the  fore  with  foft: 
fponge  to  abforb  the  matter,  and  by  frequent  drefTmgs  ; 
for,  although  the  fores  fhould  never  be  more  expofed 
to  the  air  than  is  necefl'ary,  yet  whenever  the  difcharge 
is  copious,  there  will  be  more  rilk  from  allowing  the 
parts  to  be  long  immerfed  in  matter,  than  from  a  fre- 
quent renewal  of  the  drefTmgs. 

When  the  difcharge  from  compound  fradures  is 
exceflive,  and  cannot  be  lefl'ened  by  the  means  I  have 
mentioned,  it  will  often  be  found  to  proceed  from  a 
portion  of  loofe  bone  that  has  not  been  earlier  notic- 
ed. In  this  fuuation,  we  fliould  examine  the  fore  with 
as  much  attention  as  poffible ;  and  wherever  a  piece 
of  loofe  bone  is  difcovered,  it  ought  to  be  taken  out 
ekher  at  the  fore  itfelf,  or  by  a  counter  opening,  if  it 
appears  that  in  this  manner  it  can  be  more  eafily  done. 
In  making  an  examination  for  this  purpofe,  the  finger 
alone  fliould  be  employed  when  the  opening  is  fo  large 
as  to  give  it  accefs  ;  for  in  this  manner  we  do  lefs 
harm  than  with  a  probe  ;  and  at  the  fame  time  we  dif- 
cover  the  real  ftate  of  the  parts  with  jriore  precifion. 
When  it  is  necelfary  to  ufe  a  probe,  it  fliould  be  done 
with  caution,  for  much  mifchief  is  frequently  done 
where  probes  are  ufed  with  freedom. 


382  Of  Compound  FraBures.     Chap.  XX^ 

If,  inflead  of  producing  a  difcharge  of  matter,  the 
inflammation  fliould  end  in  gangrene,  the  hazard  be- 
comes ftill  greater  than  it  ever  can  be  from  the  mofl 
extenfive  abfcefs.  Having  already,  in  Chapter  I.  con- 
fidered  the  fubjecl  of  gangrene,  I  muft  now  refer  to 
that  part  of  the  work.  In  a  following  chapter,  I  fhall 
have  an  opportunity  of  mentioning  the  period  at  which 
amputation  of  limbs,  attacked  with  gangrene,  fhould 
be  advifed. 

In  confidering  this  fubjeft,  fome  will  fuppofe  that  I 
fliould  have  given  more  particular  directions  for  fe- 
curing  fractured  limbs  in  their  fituation,  efpecially  in 
compound  fracture ;  but,  as  I  know  of  no  method  of 
effecling  this  with  fuch  certainty  and  eafe  as  the  one 
that  I  have  defcribed,  I  confider  it  as  unnecelTary  to 
enumerate  all  the  means  that  have  been  propofed  for 
it.  In  particular  circumftances,  thofe  that  I  have  de- 
fcribed in  the  eleventh  fedion  of  this  chapter,  the  ma- 
chines of  Mr.  Gooch,  and  Dr.  Aitken,  may  prove 
ufeful  for  keeping  the  fraftured  bones  extended  ;  and 
much  advantage  may  certainly  be  derived  from  them 
in  giving  a  fteady  fupport  to  fraftured  limbs,  when  it 
is  necefl'ary  to  move  a  patient  from  one  part  to  anoth- 
er :  but  in  common  pratlice,  I  can  without  hefitation 
fay,  that  no  advantage  is  derived  from  any  infl:rument 
of  this  kind  that  I  have  ever  known  ufed  ;  and  few,  I 
believe,  have  paid  more  attention  to  this  branch  of 
bufmefs  than  I  have  often  had  occafion  to  do. 


1 


Sect.  I.  General  Rsmarks,  kc»  383 


CHAPTER     XL. 

OF    LUXATIONS. 

SECTION   I. 

General  Remarks  on  Lu>:atkm. 

A  BONE  is  faid  to  be  luxated  where  that  part  of 
it  forming  a  joint  is  difplaced.  When  the  tnd 
of  a  bone  is  forced  entirely  out  of  its  correfponding 
cavity,  the  diflocation  is  faid  to  Be  complete  ;  and  we 
term  it  incomplete,  where  any  part  of  the  bone  refts 
upon  the  edge  of  the  focket. 

Luxations  may,  with  the  fame  propriety  as  frac- 
tures, be  divided  into  fnnple  and  compound.  Where 
the  end  of  a  bone  is  merely  difplaced  we  term  it  a 
fnnple  luxation  ;  but  where  this  is  accompanied  with 
a  correfponding  wound  in  the  foft  parts,  laying  open 
the  cavity  of  a  joint,  we  fay  that  the  luxation  is  com- 
pound. By  fome  praditioners  the  term  compound  is 
applied  to  diflocations  accompanied  v/ith  fractures  of 
the  contiguous  bones,  whether  the  teguments  be  in- 
jured or  not.  We  fay,  however,  with  more  propriety, 
that  a  luxation  in  fuch  circumftances  is  of  a  compli- 
cated nature. 

For  the  moft  part  luxations  are  produced  by  exter- 
nal violence,  and  appear  as  the  immediate  confequen- 
ces  of  fome  confiderable  force  apphed  to  the  injured 
parts.  They  are  particularly  apt  to  occur  in  leaping- 
and  falling ;  from  blows,  and  from  violent  twifls  and 
diftradlions  of  the  diiferent  bones  of  a  limb  :  but  they 
are  alfo  produced  by  other  caufes  ;  by  a  morbid  weak- 
nefs  or  relaxation  of  the  ligaments  and  mufcles  of  a 
joint,  which  fometimes  occur  as  the  confequences  of 
palfy  and  long  continued  rheumatifm  j  and  by  the  end 


:hap.  XL.    j 


384  General  Remarks  Chap. 

of  a  bone  being  puflied  from  the  cavity  in  which  it 
was  lodged,  by  matter  colleded  in  it,  or  by  tumors 
and  exoftofes. 

Diflocations  produced  by  external  violence,  are 
chiefly  the  objects  of  furgery.  The  fymptoms  ufual- 
ly  induced  by  thefe,  are,  inability  to  move  the  injured 
limb ;  pain,  tenfion,  and  deformity  in  the  part  aft'eft- 
ed ;  and  in  fome  cafes  inflammation,  fubfultus  tendi- 
num,  and  fever. 

In  general,  the  motion  of  the  limb  is  impaired  in 
proportion  to  the  extent  of  the  luxation  ;  but  in  fome 
cafes,  even  the  moft  partial  luxation  renders  the  joint 
perfeln:ly  ftiff  and  immoveable,  and  creates  the  moft 
exquifite  pain  on  every  attempt  to  move  it.  This  is 
particularly  the  cafe  fti  partial  diflocations  of  the  large 
joints. 

The  deformed  or  altered  appearance  of  a  joint,  with 
which  luxations  are  always  accompanied,  mufl:  necef- 
farily  be  in  proportion  to  the  extent  of  the  injury  ; 
but  this  is  not  the  cafe  with  the  other  fymptoms :  for 
fubfultus  tendinum,  inflammation  and  fever,  are  often 
excited  in  a  greater  degree  by  partial  diflocations, 
where  the  ends  of  bones  are  not  much  moved  from 
their  fituation,  than  where  they  are  entirely  forced 
from  their  fockets,  owing  to  a  circumflance  that  we 
Diall  prefently  endeavour  to  explain. 

The  firfl;  approach  of  fweUing  in  diflocation,  is  al- 
ways of  the  inflammatory  kind,  and  it  is  a  neceflary 
eft'eft  of  the  violence  done  to  the  injured  parts.  This, 
however,  fliould  be  difl:inguiflied  from  a  fecondary 
fwelling  to  which  diflocations  are  liable,  an  extenfive 
tumefadion  that  in  fome  cafes  fpreads  over  all  the  un- 
der part  of  the  limb,  and  which  feems  to  originate 
from  a  different  caufe.  Infl:ead  of  being  red,  tenfe, 
and  painful,  the  teguments  are  pale,  foft,  and  oedema- 
tous  ;  owing,  I  fuppofe,  to  the  lymphatic  veflTels  of 
the  limb  being  compreflfed  by  the  end  of  the  difplaced 
bone.  This  kind  of  fwelling  is  mofl;  frequent  in  dif- 
locations of  the  femur  and  humerus ;  in  which  alfo 


Se£l.  L  on  Luxations.      .  385 

confiderable  numbnefs  or  diminifhcd  fenfibllity  is  apt 
to  take  place  from  the  comprelTion  of  the  nerves  of 
the  hmb. 

It  is  of  much  importance  to  dlflingiiifh-  diflocation« 
from  other  affections  of  the  joints,  and  to  afcertain  to 
what  extent  the  bones  are  moved  from  their  fituation. 
In  compound  luxations  the  nature  of  the  injury  is  ob- 
vious ;  and,  for  the  mod  part,  it  is  fufiiciently  evident 
where  bones  are  completely  diflocated ;  but  partial 
diflocations  are  often  not  to  be  difcovered  but  by  the 
moll:  minute  examination :  they  therefore  frequently 
pafs  unnoticed,  or  are  confidered  as  fprains,  and  con- 
tufions  ;  and  thus,  where,  with  due  attention  on  the 
part  of  the  practitioner,  a  cure  might  frequently  be 
performed,  patients  are  often  rendered  lame  and  mife- 
rable  for  life. 

The  fymptoms  that  I  have  enumerated  are  com- 
mon to  all  diflocations.  In  fpeaking  of  particular  lux- 
ations, I  (hall  have  occafion  to  mention  the  peculiari- 
ties of  each,  and  I  fliall  endeavour  to  do  it  in  fuch  a 
manner  as  may  with  moft  certainty  prevent  thofe  un* 
fortunate  occurrences  to  which  I  allude. 

In  forming  a  prognofis  of  the  event  of  luxations, 
that  is,  of  the  pradicability  of  their  redudion,  and  of 
the  termination  of  the  fymptoms  with  which  they  are 
attended,  various  circumftances  require  attention  :  the 
form  and  flruclure  of  the  different  joints  ;  the  nature 
and  extent  of  the  luxation,  together  with  the  degree 
of  violence  by  which  it  was  produced,  and  the  circum- 
ftances  with  which  it  may  be  compHcated ;  and,  lafl- 
ly,  the  duration  of  the  injurv. 

The  fkeleton  is  commonly  had  recourfe  to  for  a 
knowledge  of  the  joints  ;  but  although  every  fludent 
fhould  be  acquainted  with  the  articulations  in  a  dry 
ftate,  we  fliould  by  no  means  reft  fatisfied  with  this. 
In  the  treatment  of  luxations,  it  is  much  more  necef- 
fary  to  have  an  exact  knowledge  of  the  joints  in  a  re- 
cent ftate  ;  of  the  cartilages,  ligaments,  and  tendons. 

Vol.  III.  B  b 


385  Gene  fa!  Remarh  Chap.  XL. 

with  which  the  bones  are  conneded,  as  well  as  of  the 
contiguous  parts  in  which  the  heads  of  the  difplaced 
bones  may  happen  to  be  lodged  :  otherwife  our  ideas 
of  the  nature  of  thefe  injuries,  and  of  the  means  that 
will  mofl:  probably  prove  fuccefsful  in  the  redudion 
of  difplaced  bones,  mud  be  very  imperfedt. 

I  cannot  here  enter  upon  a  minute  defcription  of 
every  joint,  as  it  would  lead  to  an  extent  of  difcuffion 
inconfiflent  with  the  nature  of  this  work.  Referring 
to  the  proper  fources  for  more  particular  information, 
I  (hall  here  only  obferve,  that  it  is  chiefly  thofe  joints 
that  are  poflefled  of  much  motion  in  which  we  meet 
with  luxations.  Of  thefe,  there  are  two  varieties. 
The  one  termed  the  junction  by  ball  and  focket,  where 
the  head  or  end  of  one  bone  is  received  into  the  cavi- 
ty of  another ;  and  the  other  termed  by  anatomifts 
ginglimus,  or  the  hinge-like  joint,  from  its  refemblance 
to  the  hinge  of  a  door.  In  this  the  joint  is  formed 
by  different  parts  of  one  bone  being  received  into 
cavities  or  indentations  of  another.  The  former  ad- 
mits of  the  moft  extenfive  motion,  as  is  exemplified 
in  the  joint  of  the  humerus  with  the  fcapula,  and  in 
that  of  the  femur  with  the  ofla  innominata  ;  while  the 
latter  does  not  admit  of  more  than  that  of  flexion  and 
extenfion,  as  is  the  cafe  in  the  elbow  and  knee.  In 
thefe  we  accordingly  find,  that  this  more  limited  mo- 
tion to  which  they  are  confined,  renders  them  lefs  lia- 
ble to  luxations ;  while  the  free  motion  of  the  others 
expofes  them  to  be  frequently  luxated,  as  is  more  par- 
ticularly the  cafe  in  the  joint  of  the  humerus,  from  the 
cavity  in  which  the  head  of  that  bone  is  lodged  being 
of  no  great  depth. 

Befides  the  ufual  coverings  of  teguments,  mufcles, 
and  tendons,  in  common  to  joints  with  the  reft  of  the 
body,  every  joint  poflefled  of  much  motion  is  provid- 
ed with  what  is  termed  a  capfular  ligament ;  which 
is  a  firm  fomewhat  elaftic  fubftance,  forming  a  kind 
of  pouch  or  bag,  that  completely  furrounds  the  ar- 
ticulation, and  ferves  at  the  fame  time  to  retain  the 


Se£l.  I.  (/n  Luxations,  387 

ends  of  the  bones  together,  and  to  contain  a  thin 
tranfparent  fluid,  the  fynovia,  for  the  purpofe  of  lubri- 
cating the  cartilages  that  cover  the  ends  of  the  bones. 
Praftitioners  are  not  agreed  whether  in  luxations 
the  capfular  ligaments  of  joints  are  ruptured  or  not. 
As  it  has  appeared  on  diifedion,  in  a  few  inftances, 
that  the  ligament  was  ruptured,  fome  have  concluded 
that  it  is  the  cafe  in  all ;  while  others  are  of  opinion, 
that  the  ligament  always  remains  entire,  except  where 
the  luxation  has  been  the  confequence  of  very  fevere 
and  unufual  degrees  of  violence. 

,  The  refult  of  my  obfervation  on  this  point  is,  and 
I  fpeak  from  many  opportunities  of  difleding  difloca- 
ted  joints  after  death,  that  partial  luxations  may  hap- 
pen without  any  rupture  of  the  capfular  ligament ; 
but  that  it  is  always  ruptured  in  complete  luxations 
produced  by  external  violence  ;  nay,  that  the  liga- 
ment is  often  torn  from  its  infertion  round  the  neck 
of  the  bone.  Where  the  head  of  a  bone  is  gradually 
pufhed  from  its  focket  by  the  flow  formation  of  a  tu- 
mor within  the  joint,  and  where  the  ligament  is  per- 
haps nmch  relaxed  by  difeafe,  a  luxation  may  happen 
without  either  rupture  or  laceration :  but  we  cannot 
fuppofe  that  fuch  a  firm  fubftance  as  a  ligament  in  a 
ftate  of  health  always  is,  will,  without  burfling,  yield 
to  the  fudden  impulfe  produced  by  the  complete  dif- 
location  of  the  head  of  a  bone,  and  where  the  dif- 
placed  bone  is  in  fome  cafes  almoft  inftantaneoufly 
forced  to  the  diftance  of  feveral  inches  from  its  natur- 
al fituation.  Different  inftances  are  upon  record  of 
this  opinion  being  fupported  by  the  diflection  of  dif- 
located  joints  after  death  ;  and  were  it  neceffary,  I 
could  add  feveral  others  that  have  fallen  within  my 
own  obfervation. 

I  mentioned  above,  that  the  pain  attending  partial 

diflocations  is  commonly  very  fevere  on  every  attempt 

to  move  the  joints.     For  the  moft  part,  indeed,  it  is 

more  exquifite  than  it  ufually  is  where  the  luxation 

B  B  2 


3^8  General  Remarks  Chap.  XL. 

is  complete  ;  and  we  conclude  that  It  proceeds  from 
the  capfular  ligament  being  overft  retched,  and -from 
the  ends  of  the  difplaced  bones  continuing  to  act 
againft  it  inftead  of  palling  freely  through  it. 

In  judging  of  a  luxation,  the  diftance  to  which  the 
head  of  the  difplaced  bone  is  forced,  and  the  degree 
of  violence  by  which  it  was  produced,  require  parti- 
cular attention.  When  a  bone  is  only  partially  diflo- 
cated,  although  the  pain  may  be  very  acute,  yet  the 
redudion  will  be  accomplilhed  both  with  more  eafe 
and  certainty  than  if  the  fame  bone  had  been  forced 
completely  out  of  its  fituation.  And  where  the  joint 
has  not  fuffered  any  extraordinary  violence,  the  in- 
flammation and  other  concomitant  fymptoms  will  not 
prove  fo  formidable  as  they  commonly  do  where  the 
capfular  ligament  and  other  foft  parts  have  been  much 
flretched,  or  otherwife  feverely  injured. 

One  of  the  mod  unfavourable  circumftances  with 
which  a  luxation  is  ever  attended,  is  a  fradlure  of  one 
or  both  of  the  bones  forming  the  joint.  Even  a  frac- 
ture of  the  difplaced  bone  proves  always  diflrefsful, 
efpecially  if  it  is  broken  near  to  its  neck,  as  in  this 
cafe  it  can  fcarcely  be  laid  hold  of  for  the  purpofe  of 
reducing  it ;  but  the  riik  attending  it  is  much  greater 
when  the  bone  forming  the  focket  into  which  it  Ihould 
be  received  is  alfo  broken  :  for  we  know  from  expe- 
rience, that  fraftures  of  thefe  parts  are  more  apt  to 
excite  fevere  degrees  of  inflammation,  as  well  as  ex- 
tenfive  fuppurations,  than  fradures  of  any  of  the  long 
bones.  And  when  the  focket  is  broken,  there  is  al- 
ways much  hazard  of  the  joint  being  rendered  fliifi" 
for  life,  even  when  the  reduction  of  the  difplaced  bone 
is  accompliflied  in  the  eafieft  manner. 

A  diflocation  being  more  or  lefs  recent,  Is  the  next 
point  that  merits  attention  ;  for  we  know  that  luxa- 
ted bones  are,  cseteris  paribus,  more  eafdy  reduced 
foon  after  being  difplaced  than  when  much  time  has 
elapfed.  While  the  injury  is  recent,  the  bone  returns 
with  more  eafe  along  the  parts  which  it  has  juft  tra- 


Se£l.  I.  on  Luxations,  389 

verfed,  than  it  poffibly  can  do  after  lodging  feveral 
weeks  or  months  among  the  contiguous  mufcles  ; 
where  the  head  of  it,  inftead  of  being  loofe,  as  is  ufu- 
ally  the  cafe  at  firfl,  forms  a  focket  for  itfelf,  and  is 
commonly  firmly  grafped  by  fome  of  thofe  mufcular 
fibres  with  which  it  is  furrounded.  At  this  period 
too,  the  cavity  from  whence  it  was  diflodged  may 
probably  be  in  fome  degree  filled  up  by  the  contigu- 
ous foft  parts  :  not  that  the  fynovia  ever  becomes  in- 
fpiffated,  fo  as  to  produce  this  effed: ;  for  although 
this  has  by  many  been  fuppofed  to  happen,  and  vari- 
ous means  have  been  propofed  for  preventing  and  re- 
moving it,  yet  we  now  know  that  the  opinion  is  ill 
founded.  No  infpiffation  of  this  fluid  has  ever  been 
difcovered  by  difledion,  although  ftiff  joints,  where 
this  ftate  of  the  fynovia  was  previoufly  confidered  as 
the  caufe,  have  often  been  laid  open  for  the  purpofe. 
But  although  the  cavity  of  a  joint  may  not  be  filled 
up  by  the  efl'edl  of  any  particular  aff'edion  of  the  fy- 
novia, there  is  much  reafon  to  fuppofe,  that  in  courfe 
of  time  it  will  be  diminiflied  by  the  confi:ant  adion  of 
the  contiguous  mufcles ;  which  will  not  only  force  the 
cellular  fubftance,  fat,  and  other  foft  parts  with  which 
it  is  covered,  into  it,  but  may  even  have  fome  effeO: 
in  comprcfling  the  bone  itfelf,  or  the  cartilaginous 
brim  with  which  the  bone  is  ufually  covered. 

Thefe  are  the  circumflances  in  diflocations  which 
more  particularly  require  attention  ;  but  we  have  alfo 
to  remark,  that  the  patient's  age  and  general  ftate  of 
health,  have  fome  influence  in  the  reduftion  of  a  dif- 
located  bone.  Diflocations  are  more  eafily  reduced 
at  fome  ages,  and  in  particular  habits  of  body,  than 
in  others.  Thus,  in  advanced  periods  of  life,  and  in 
weak  delicate  confl:itulions,  where  the  mufcles  give 
little  refifl:ance,  difplaced  bones  are  more  eafily  moved 
than  in  the  vigour  of  youth,  and  in  robufl:  habits  of 
body,  where  the  fuperior  flirength  of  the  mufcles  has 
a  confiderable  efled:  in  preventing  it. 


390  General  Remarks  Chap.  XL. 

In  the  treatment  of  diflocations,  the  objeds  we  have 
in  view  are,  to  put  the  bone  that  is  difplaced  into  its 
natural  fituation,  with  as  much  eafe  and  expedition 
as  poflible  ;  to  retain  it  in  this  fituation  till  the  injur- 
ed parts  have  recovered  their  tone  ;  and  to  obviate 
pain,  inflammation,  and  any  other  fymptom  that  re- 
quires attention. 

Before  proceeding  to  the  redu6lion  of  diflocations, 
we  fliould  examine  the  contiguous  foft  parts,  to  fee 
whether  they  are  in  a  fit  ftate  for  it  or  not ;  for  al- 
though the  fooner  the  operation  is  attempted,  the  more 
certain  will  our  fuccefs  in  general  be  ;  yet  whenever 
the  furrounding  teguments  and  mufcles  are  much 
contufed  and  inflamed,  it  is  better  to  allow  the  pain 
and  fwelling  to  fubfide  before  we  endeavour  to  re- 
duce the  bone ;  at  leafl:  I  have  always  been  in  the 
practice  of  this.  I  never  obferved  that  any  bad  con- 
fequences  enfued  from  it ;  and  I  have  known  much 
mifchief  done  by  a  limb  being  ftretched  while  the 
parts  furrounding  a  diflocated  joint  have  been  much 
fwelled  and  inflamed. 

In  fuch  circumftances,  therefore,  we  fhould  endea- 
vour, by  local  bloodletting  with  leeches,  by  the  ufe  of 
faturnine  applications,  a  low  regimen,  and  putting  the 
limb  in  an  eafy  relaxed  poflure,  to  remove  the  inflam- 
mation before  any  attempt  is  made  for  reducing  the 
bone. 

In  almofl  every  diflocation,  one  bone  only  is  dif- 
placed :  the  other  bone  or  bones  of  which  the  joint 
is  formed  remain  in  their  natural  fituation  ;  and  it 
will  be  found  perhaps  univerfally,  that  it  is  the  bone 
connefted  vi^ith  the  inferior  part  of  a  limb  that  is  forc- 
ed from  its  fituation  ;  the  bone  forming  the  upper 
part  of  the  joint,  if  it  be  not  fractured,  being  feldom 
in  any  refpecl  altered  :  in  the  redudion  therefore  of 
luxations,  the  only  attention  to  be  given  to  the  upper 
part  of  a  limb,  is  to  keep  it  firm  and  fteady,  while  we 
endeavour  by  the  eafiefl  and  mofl  effectual  means  to 
replace  the  inferior  part  of  it. 


Sed.  I.  on  Luxations.  391 

A  perfon  not  acquainted  with  anatomy,  might  be 
led  to  fuppofe  that  this  may  always  be  readily  done ; 
as  he  will  be  apt  to  conclude,  that  the  fame  degree  of 
force  by  which  a  bone  is  pufhed  out  of  its  place,  will 
with  equal  eafe  replace  it.  This  would  no  doubt  be 
A.  the  cafe,  were  it  the  bone  only  upon  which  we  had  to 
*  a6t,  or  if  the  bone  was  conneded  with  inorganic  mat- 
ter only  that  would  not  refift  the  means  employed  to 
reduce  it :  but  every  joint  being  either  partly  furround- 
ed  by,  or  much  connected  with  mufcles,  the  contrac- 
tile power  with  which  thefe  are  endowed,  ads  with 
much  force  and  advantage  againft  every  attempt  that 
can  be  made  for  the  redudion  of  the  bone  ;  for  they 
not  only  draw  it  beyond  the  end  of  the  contiguous 
bone  againft  which  it  ought  to  be  placed,  but  they 
often  pull  it  out  of  its  natural  diredion,  and  fix  it 
firmly  in  fome  neighbouring  cavity,  from  whence  it 
is  diflodged  with  difficulty ;  while  the  ftimulus  create 
ed  by  every  trial  that  is  made  for  replacing  the  bone, 
is  apt  to  excite  a  further  exertion  of  the  mufcles,  and 
to  increafe  the  difficulty  of  the  redudion. 

It  is  therefore  obvious,  that  in  the  redudion  of  eve* 
ry  diflocated  bone,  the  mufcles  with  which  it  is  con- 
neded  (hould  be  put  as  much  as  poffible  into  a  ftate 
of  relaxation ;  for  in  this  fituation,  the  refiftance 
which  they  give  to  the  force  employed  for  moving  the 
bone  is  inconfiderable,  when  compared  with  what  is 
required  for  the  fame  purpofe,  when  they  are  kept  in 
a  ftate  of  extenfion.  In  the  one,  it  is  ufually  done 
with  eafe,  both  to  the  patient  and  furgeon  ;  while  in 
the  other,  that  is,  while  a  limb  is  much  ftretched  or 
extended,  it  is  with  the  utmoft  difficulty  that  a  diflo- 
cated bone  can  be  moved. 

By  relaxing  all  the  mufcles  of  a  limb,  we  may  in 
general  obtain  a  fufficient  force  for  reducing  a  luxa- 
tion merely  by  the  hands  of  affiftants ;  but  in  fome 
inftances  more  force  is  required  than  can  be  appHed 
in  this  manner  :  in  this  cafe,  various  inftruments  have 
been  propofed  foi-  increafmg  our  powers  of  exten- 


392  General  Remarks  Chap,  XL. 


/ 


fion ;  feme  of  which,  and  perhaps  the  moft  ufeful, 
are  dehneateJ  iii  Plates  LXXXVII.  LXXXVIII.  and 
LXXXIX. 

But  whether  we  find  It  neceflary  to  ufe  machines  of 
this  kind  or  not,  no  more  force  fliould  be  ever  em- 
ployed than  is  juft  requifite;  and  it  ought  always  to 
be  applied  in  a  flow  gradual  way,  by  which  there  is 
much  lefs  rifk  of  any  harm  being  done,  than  when  the 
mufcles  of  a  limb  are  forcibly  and  fuddenly  ftretched  ; 
and  it  will  alfo  be  underftood,  that  the  whole  force 
ufed  lor  the  reduction  of  a  diflocated  bone,  fhould  be 
applied  to  that  bone  only,  and  not  to  any  other  part 
of  the  limb. 

Befides  the  refiftance  arifing  from  the  aftion  of  the 
mufcles,  we  fometimes  meet  with  much  difficulty  from 
the  projecling  end  of  a  diflocated  bone  having  palled 
that  of  a  contiguous  bone.  In  this  cafe  the  extenfion 
is  to  be  made  in  fuch  a  direction  as  will  bell  obviate 
this  relative  fituation  of  the  parts. 

In  extending  a  limb  for  the  purpofe  of  reducing  diflo- 
cations,  the  extenfion  fhould  be  carried  fo  far  as  to 
diflodge  the  difplaced  bone,  and  to  bring  the  end  of  it 
on  a  line  with  the  end  of  the  other  to  which  it  is  to 
be  oppofed,  otherv/ife  no  advantage  v.  ill  be  gained  by 
the  operation  ;  for  while  any  part  of  one  bone  projects 
pad  the  extremity  of  the  other,  no  means  that  we  can 
employ  will  be  able  to  replace  it,  unlefs  fuch  a  force 
is  made  ufe  of,  (as  has  fometimes  happened,)  as  is  fuf- 
ficient  for  breaking  off  the  projecling  part  of  the  bone ; 
■while,  on  the  contrary,  the  redudion  is  always  accom- 
pliflied  in  the  eafiefl  manner,  as  foon  as  the  difplaced 
bone  is  drawn  freely  pad  all  the  projefting  parts  of 
the  other ;  nay,  when  the  end  of  a  difplaced  bone  is 
brought  to  this  fituation,  it  would  be  difficult  to  pre- 
vent it  from  paffi^ng  inilantaneoufly  into  its  natural 
fituation  ;  fo  that  in  the  reduction  of  diflocations,  our 
chief  object  is  to  make  a  fufficient  degree  of  extenfion, 
when  the  ordinary  action  of  the  mufcles  will  for  the 


Seft.  r.  on  Luxations,  393 

mofl;  part  replace  the  bone :  or  when  this  fails,  the 
nK)fl  gentle  preiTure  will  prove  fufficient. 

The  diflocated  bone  being  reduced,  it  feldom  proves 
difficult  to  retain  it  in  its  fituation,  unlefs  it  has  often 
been  difplaced  before :  the  furefl  means  of  retaining 
it,  is  to  put  the  limb  into  a  relaxed  pofture,  and  to 
fupport  the  bone  that  has  been  jufl  replaced  with  a 
proper  bandage,  till  the  furrounding  foft  parts  have  re- 
covered their  natural  tone. 

The  fymptoms  that  prove  mofl:  urgent  in  difloca- 
tions,  both  iDcfore  and  after  the  bones  have  been  re- 
duced, are,  pain,  inflammation,  and  fwelling.  For  the 
mofl:  part  thefe  fymptoms  abate  foon  after  the  reduc- 
tion ;  but  while  any  degree  of  inflammation  contin- 
ues, repeated  applications  of  leeches  Ihould  be  advifed 
as  the  mofl:  eflcdual  remedy  :  and  as  this  fymptom  is 
to  be  confidered  as  the  caufe  of  all  the  others,  as  well 
as  of  thofe  chronic  pains  to  which  joints  are  liable, 
that  have  ever  been  diflocated,  it  therefore  merits  par- 
ticular attention.  But  this  fubjeft  having  already  been 
fully  confidered,  when  treating  of  contufions,  I  mufl; 
now  refer  to  what  was  then  faid  upon  it  in  Chapter 
II.  Seaion  IT. 

In  the  firft  part  of  this  fe£tion,  I  have  faid  that  lux- 
ations are  fometimes  combined  with  fractures  of  the 
difplaced  bones.  When  a  bone  is  fradured  at  a  con- 
fiderable  diftance  from  the  luxated  joint,  we  may  for 
the  mofl:  part  be  able  to  reduce  the  luxation  immedi- 
ately ;  and  this  being  done,  the  fracture  fliould  be 
treated  in  the  ufual  way  :  but  when  a  bone  is  fractur- 
ed fo  near  to  the  luxated  joint  that  it  cannot  be  laid 
hold  of,  the  cafe  is  thereby  rendered  both  difficult  and 
uncertain.  In  the  fmaller  joints,  as  in  thofe  of  the 
fingers  and  toes,  the  difplaced  portion  of  bone  may  in 
fome  inftances  be  puflied  into  its  fituation  ;  but  in  all 
the  larger  joints,  particularly  in  the  hip  joint,  and  in 
that  of  the  flioulder,  we  mufl:  firfl:  allow  the  fracture 
to  heal,  and  the  union  of  the  fradured  bones  to  be 


Of  Luxations  of  the 


Chap.  XL. 


perfe£lly  firm,  before  we  can  exped  to  reduce  the  lux- 
ation. 

In  compound  luxations,  that  is,  where  joints  arc 
not  only  luxated  but  laid  open  by  external  injuries, 
the  treatment  that  I  have  advifed  in  compound  frac- 
tures applies  with  equal  propriety  :  almoft  all  the  ob- 
fervations  indeed  that  were  made  upon  the  one  will 
apply  with  nearly  equal  force  to  the  other  :  fo  that  at 
prefent  I  fliall  refer  to  Section  XV.  of  the  laft  Chap- 
ter where  the  fubjeft  was  fully  confidered. 

I  may  juil  Ihortly  obferve,  that  after  the  luxated 
bones  are  replaced,  and  the  limb  laid  in  a  proper  pof- 
ture,  our  next  obje6:  is  to  prevent  inflammation  :  this 
we  do  with  moft  certainty  by  copious  bloodletting, 
with  leeches  applied  near  to  the  injured  parts  ;  dreff- 
ing  the  fores  with  faturnine  cerate,  or  any  mild  oint- 
ment ;  moderating  the  pain  with  adequate  dofes  of 
opiates ;  and  a  low  regimen. 

This  being  done,  we  have  to  endeavour  to  prevent 
the  m.atter  of  the  fore  from  lodging  about  the  joint, 
by  placing  the  limb  in  fuch  a  manner  that  it  may  moft 
readily  run  off :  if  this  fails,  we  fometimes  fucceed  by 
dreffing  the  fore  more  frequently,  and  abforbing  the 
matter  with  a  bit  of  fponge ;  or,  when  the  quantity  of 
matter  is  confiderable,  by  a  counter  opening  made  in 
a  more  depending  part  of  the  limb. 

When  mortification  takes  place,  it  is  to  be  treated 
in  the  manner  I  have  advifed  in  Chap.  I.  Se£l.  IV. 

All  that  I  have  hitherto  faid,  relates  in  general  to 
luxations  produced  by  external  violence.  When  they 
proceed  from  the  heads  of  bones  being  pufhed  from 
their  fockets,  either  by  tumors  of  a  flefhy  or  offeous 
nature,  or  by  collections  of  matter,  they  may  almoft 
in  every  in  fiance  be  confidered  as  incurable :  when 
the  joint  is  fo  fituated  that  the  difeafed  parts  can  all 
be  removed,  this  meafure  fhould  be  advifed  ;  but 
when  this  cannot  be  completely  accompliflied,  all  that 
art  fhould  attempt  is,  to  give  as  free  a  difcharge  as 


Sect.  II.  Bones  of  the  Cranium.  395 

poffible  to  any  matter  that  may  form,  and  to  fupport 
the  conflitution  with  fuch  a  diet,  as  may  prevent  it 
from  being  too  much  reduced  by  the  difcharge. 

Diflocations  are  fometimes  the  confequence  of  re- 
laxation of  the  ligaments  and  tendons  by  which  the 
bones  in  a  healthy  ftate  are  kept  together.  This  re- 
laxation is  feldoni  fo  completely  removed  as  t(^  pre- 
vent the  bones  from  falling  out  from  time  to  time  ; 
but  the  inconveniency  may  in  fome  meafure  be  obvi- 
ated by  fupporting  the  limb  with  a  bandage  ;  by  en- 
deavouring to  reftore  the  tone  of  the  relaxed  parts  by 
cold  bathing  ;  and,  in  fome  inftances,  electricity  has 
appeared  to  prove  ufeful. 

We  fliall  now  proceed  to  fpeak  of  diflocations  from 
external  violence  as  they  occur  in  particular  parts. 


SECTION    11. 

Of  Luxations  of  the  Bones  of  the  Crajiium. 

THE  bones  of  the  cranium  are  frequently  feparat- 
ed  from  each  other  at  the  futures  in  hydroce- 
phalus internus.  This,  however,  can  feldom  become 
an  obje£t  of  furgery.  If  fuch  colledions  (hall  ever 
be  removed  by  medicine,  all  that  art  can  do  further  is 
to  fupport  the  parts  with  a  bandage. 

We  alfo  find  that  openings  are  in  fome  inftances 
produced  at  the  futures  by  external  violence,  particu- 
larly by  falls  from  heights.  This,  however,  very  com- 
monly proves  fatal.  I  have  only  met  with  one  in- 
ftance  of  a  patient  under  fuch  circumftances  recover- 
ing. All  that  in  this  fituation  can  with  propriety  be 
done,  is  to  fupport  the  parts  by  gentle  preiTure  with  a 
proper  bandage  ;  to  prefcribe  bloodletting  and  other 
evacuations  according  to  the  violence  of  the  fymptoms  ; 
and  to  keep  the  patient  quiet,  and  under  proper  con- 
finement during  the  cure. 


39^  Of  Luxaiicns  cfihs  Chap.  XL. 

SECTION    m. 

Of  Luxntions  of  the  Bones  of  the  Nofe. 

'  I  iJiE  bones  of  the  nofe  are  fo  firmly  united,  and 
X  ferve  fo  effectually  to  fuppoit  each  other,  that 
they  are  not  often  diflocated. 

Thefe  bones  being  thinly  covered  with  foft  parts, 
luxations  in  any  part  of  the  nofe  are  eafily  difcovered 
by  the  touch,  as  well  as  by  the  deformity  which  they 
produce. 

In  the  reduction  of  luxations  of  thefe  bones,  the  pa- 
tient fhould  be  feated  oppofite  to  a  proper  light,  with 
an  affiftant  behind  fupporting  his  head  ;  and  the  fur- 
geon  (landing  before,  fliould  endeavour  to  replace  the 
bones  with  as  much  accuracy  as  poffible.  In  general, 
this  may  be  done  v/ith  the  fingers  alone ;  but  when 
one  of  the  bones  is  puflied  inwards,  we  do  it  more 
eafily  by  pufhing  one  of  the  tubes  in  Plate  XXVI.  fig, 
3.  up  the  correfponding  noffcril,  in  order  to  elevate  the 
depreffed  piece  ;  and  if  the  tube  is  guarded  with  fome 
plies  of  foft  lint,  it  may  be  retained  m  its  fituation  till 
there  is  no  longer  any  rilk  of  the  bone  flipping  out. 

When  either  of  the  bones  of  the  nofe  is  puflied  out- 
wards, it  mufl:  firfl:  be  exaftly  replaced,  and  afterwards 
retained  in  its  fituation  by  a  proper  application  of  a 
double  headed  roller. 


SECTION     IV. 

Of  Luxations  of  the  Lower  Jaw. 

THE  lower  jaw  is  conneded  by  a  very  beautiful 
mechanifm  with  the  bones  of  the  head.     In  each 
temporal  bone  there  is  an  irregular  oblong  cavity,  im- 


Sed  IV.  Lozi'er  Jaw,  397 

mediately  before  the  external  meatus  auditorlus.  In 
thefe  cavities,  the  two  condyles  of  the  lower  jaw  are 
lodged  ;  and  by  means  of  two  intermediate  loofe  car- 
tilages which  move  along  with  the  condyles,  and  w^hich 
correfpond  with  the  irregular  furfaces  of  the  cavities 
in  which  they  are  placed,  luch  a  degree  of  hrmnefs  is 
given  to  this  joint  as  would  otherwife  be  inconfiflent 
with  the  freedom  of  motion  of  which  it  is  pofleifed  ; 
for  although  the  condyles  of  the  jaw  arc  fecured  in 
their  fituation,  by  different  ligaments,  as  well  as  by 
ftrong  mufcles,  particularly  by  the  ftrong  tendons  of 
the  temporal  mufcles  inferted  into  the  coronoid  pro- 
celTes  of  the  jaw  ;  yet  the  variety  of  motions  which 
the  under  jaw  is  conftantly  performing,  would  render 
it  very  liable  to  diflocations,  were  it  not  for  the  inter- 
vention of  thefe  moveable  cartilages ;  which  admit  of 
every  neceffary  freedom,  while  fuch  a  loofe,  extenfive 
motion  is  prevented,  as  muft  have  happened  if  the 
heads  of  the  condyles  had  been  placed  in  large  fmooth 
cavities  without  thefe  cartilages  between  them. 

The  under  jaw  cannot  be  diilocated  either  upwards, 
backwards,  or  laterally  :  it  can  only  be  diflocated  for- 
ward and  downward.  In  every  other  diredlion,  the 
condyles  are  fo  much  furrounded  with  bone,  that  they 
cannot  be  forced  out  of  their  correfponding  cavities, 
as  will  be  readily  feen  on  an  examination  of  the  flvcle- 
ton  :  but  when  the  mouth  is  widely  opened,  as  hap- 
pens in  yawning,  the  condyles  are  apt  to  flip  too  far 
over  the  anterior  boundaries  of  thefe  cavities.  In  this 
manner  a  diilocation  takes  place,  as  we  difcover  by  the 
chin  being  thrown  forward  and  dov^nward,  while  the 
mouth  remains  open,  at  the  fame  time  that  much  pain 
is  produced  by  every  attempt  to  clofe  it  ;  nor  can  the 
patient  fpeak  diftiiidly,  or  fwallow  but  with  much  dif- 
ficulty. 

In  fome  cafes,  one  fide  only  of  the  jaw  is  diflocated, 
that  is,  one  of  the  condyles  remains  nearly  in  its  nat- 
ural fituation,  while  the  other  is  thrown  entirely  out* 


39^  Of  Luxations  of  the  Chap.  XL» 

In  this  cafe,  the  jaw,  inftead  of  falling  direQly  down, 
is  pufhed  obliquely  downwards,  and  fomewhat  to- 
wards the  fide  oppofite  to  that  in  which  it  is  difloca- 
ted. 

Befides  the  fymptoms  that  I  have  mentioned  of  pain 
on  any  attempt  to  clofe  the  mouth,  and  difficulty  in 
fpeaking  and  fwallowing,  we  are  told  by  all  the  older 
writers  on  this  fubjed,  and  by  all  who  have  copied 
from  them,  that  luxations  of  the  jaw  are  apt  to  induce 
convulfions,  and  even  death.  I  have  never,  however, 
met  with  an  inftance  of  this,  nor  is  it  probable  that  it 
will  ever  happen,  unlefs  from  great  mifmanagement 
on  the  part  of  the  furgeon. 

A  luxation  of  the  jaw  being  very  diftrefsful,  and 
even  alarming  to  thofe  who  are  not  acquainted  with 
its  nature,  immediate  affiftance  is  commonly  defired  ; 
and  with  due  attention  vi^e  can  feldom  fail  to  reduce  it. 

The  patient  being  firmly  feated  on  a  low  chair,  with 
his  head  properly  fupported  behind,  the  furgeon  (land- 
ing before,  with  his  thumbs  fufficiently  guarded,  (hould 
pufh  them  as  far  as  they  will  go  between  the  teeth  of 
the  upper  and  under  jaws,  the  under  or  flat  part  of 
the  thumbs  being  applied  to  the  furface  of  the  teeth 
of  the  under  jaw  :  the  palm  of  each  hand  fhould  be 
applied  to  the  outfide,  while  with  his  fingers  he  lays 
a  firm  hold  of  the  angles  of  each  jaw.  With  the  fin- 
gers applied  in  this  manner,  he  fhould  pull  the  under 
jaw  forward  till  he  finds  it  move  fomewhat  from  its 
fituation :  and  this  being  done,  but  not  till  then,  he 
fliould  prefs  the  jaw  forcibly  down  with  his  thumbs, 
and  moderately  backwards  with  the  palms  of  his  hands ; 
when,  if  the  difl'erent  parts  of  the  operation  are  right- 
ly managed,  the  ends  of  the  bone  will  immediately  flip 
into  their  fituation  ;  upon  which  the  thumbs  fhould 
be  inflantly  withdrawn. 

In  general,  we  are  direfted  to  prefs  the  jaw  down- 
wards and  backwards  :  but  although  this  might  fuc- 
ceed  in  fome  inflances  where  the  jaw  is  diflocated  on- 


Sed.  IV.  Lower  Jaw.  399 

ly  on  one  fide,  yet  even  there  It  would  often  fail ;  and 
it  would  feldom  anfwer  when  both  condyles  are  out : 
for,  till  the  condyles  are  quite  difengaged  from  the 
bones  on  which  they  reft,  and  which  they  can  only  be 
by  puHing  the  jaw  forward,  all  the  force  we  could  em- 
ploy in  pulling  them  down  would  be  of  little  avail,  as 
I  have  often  had  occafion  to  obferve. 

I  have  defired,  in  prefilng  down  the  jaw,  that  at  the 
fame  time  it  fhould  be  prefl'ed  moderately  backwards  : 
the  flighteft  force,  however,  in  this  diretlion  is  fuffi- 
cient ;  nay,  in  fume  cafes  it  is  not  necefl'ary  ;  for  as 
foon  as  the  condyles  are  fufficiently  deprefled,  they  are 
almoft  inflantaneoufly  drawn  into  their  natural  fitua- 
tions  by  the  ordinary  adion  of  the  temporal  mufcles, 
whether  any  force  be  applied  for  this  purpofe  or  not. 

The  treatment  that  1  have  advifed  anfv/ers  equally 
well,  whether  the  jaw  be  luxated  on  one  fide,  or  on 
both  ;  but  where  one  condyle  only  is  thrown  out,  the 
force  ufed  for  deprefllng  the  jaw  fliould  be  chiefly  ap- 
plied to  that  fide. 

The  luxated  jaw  being  reduced,  the  patient  fhould 
be  advifed  to  avoid  every  caufe  that  might  have  any 
efl'ed:  in  throwing  out  the  bone  again  ;  particularly 
much  fpealdng,  gaping,  and  yawning,  as  the  condyles 
are  apt  for  a  confidcrable  time  to  be  turned  out  by 
any  of  thefe  aftions. 

In  the  reduftion  of  a  diflocated  jaw,  the  thumbs  are 
very  apt  to  be  bit  if  they  be  not  well  protected,  or  if 
they  be  not  inftantly  withdrawn  on  the  bones  flipping 
into  their  fituation.  For  the  moft  part,  the  end  of  a 
handkerchief  is  wrapped  round  them  ;  but  a  covering 
of  firm  leather  anfwers  better,  or  a  cafe  of  thin  iron 
covered  with  leather,  would  be  ftill  preferable,  as  it 
would  not  occupy  fo  much  fpace.  It  would  pafs  far- 
ther into  the  mouth,  and  would  thus  act  with  more 
advantage  in  forcing  down  the  jaw. 


400  Of  Luxations  Chap.  XL. 

SECTION     V. 

Of  Liixatiojis  of  the  Head* 

THE  head  is  connecled  in  fuch  a  manner  with  thtf 
atlas  or  firfl  vertebra  of  the  neck,  that  it  moves 
upon  it  with  eafe  and  freedom  backwards  and  forwards, 
the  two  condyles  of  the  os  occipitis  being  received  in- 
to correfponding  cavities  in  the  fuperior  oblique  pro- 
cefles  of  that  bone  :  but  the  lateral  and  rotatory  mo- 
tion of  the  head  proceeds  from  the  immediate  connec- 
tion between  it  and  the  fecond  vertebra  of  the  neck, 
by  means  of  the  proceffus  dentatus  of  that  bone  ; 
which  palling  through  the  back  part  of  the  large  cav- 
ity of  the  atlas,  is  fixed,  by  means  of  different  liga- 
ments, to  the  OS  occipitis. 

The  connection  between  the  head  and  the  firfl  of 
thefe  bones  is  fo  firm,  that  they  are  not  perhaps  ever 
feparated  by  accident ;  at  leaft,  I  have  not  heard  of 
any  inftance  of  this  being  difcovered  on  diffe^ion.  It 
rather  appears,  that,  in  luxations  of  the  head,  the  con- 
nection is  deftroyed  between  the  head  and  the  fecond 
vertebra,  the  head  being  forced  with  fuch  violence  for- 
ward as  to  -ftretch  or  rupture  the  ligaments  by  which 
the  tooth  like  procefs  of  this  bone  is  fixed  to  the  oc- 
ciput :  at  leaft,  this  has  been  found  to  be  the  cafe  in 
different  inftances  of  thefe  dillocations,  and  it  alfo  hap- 
pens in  thofe  who  die  by  hanging. 

In  every  diflocation  of  the  head,  the  head  falls  for- 
ward upon  the  breaft  ;  the  patient  is  inftantly  depriv- 
ed of  fenfibillty  ;  he  lies  as  if  he  were  dead  ;  and  he 
foon  dies  if  the  luxation  be  not  quickly  reduced.  In- 
juries of  this  kind  are  produced  molt  frequently  by 
falls  from  great  heights,  or  from  horfeback. 

Luxations  of  the  head,  for  the  moft  part,  terminate 
fatally  ;  but  as  inftances  have  occurred  where  this  has 
been  prevented  when  timous  affiftance  has  been  given, 


Sed.  VI.         of  the  Spine,  Os  Sacrum,  &c.  401 

we  have  reafon  to  think,  that  recoveries  would  be 
more  frequent  if  this  could  be  always  procured. 

Different  means  have  been  propofed  for  the  reduc- 
tion of  thefe  luxations ;  but  whatever  requires  much 
preparation  is  here  inadmiflible.  In  all  fuch  cafes, 
our  views  muft  be  inftantly  carried  mto  effeft  ;  and 
it  fortunately  happens,  that  in  perhaps  every  inftance 
they  may  be  accomplilhed  without  any  preparation. 

The  patient  being  feated  on  the  ground,  and  fup- 
ported  by  an  affiftant,  the  furgeon  (landing  behind, 
fhould  raife  the  head  from  the  breafl ;  and  the  aflift- 
ant  being  defircd  to  prefs  down  the  (boulders,  the  head 
(liould  be  gradually  pulled  ftraight  up  till  the  difloca- 
tion  is  reduced  ;  or,  if  this  does  not  happen  with  mod- 
erate extenfion,  it  may,  at  the  fame  time,  be  gently 
moved  from  fide  to  fide.  A  fudden  noife  or  crack  is 
heard  on  the  redudion  taking  place  ;  and  if  the  pa^- 
tient  be  not  entirely  dead,  an  immediate  and  perhaps 
entire  recovery  of  all  his  faculties  enfues.  In  fome 
cafes  they  have  been  completely  reftored  on  the  head 
being  replaced  ;  but  in  others  they  have  remained  long 
impaired,  and  in  fome  have  always  continued  fo. 

The  redudlion  being  accomplilhed,  the  patient 
fhould  be  immediately  laid  in  bed.  His  head  (hould 
be  kept  elevated,  and  retained  by  a  proper  bandage 
for  a  confiderable  time  in  one  pofture  ;  and  with  a 
view  to  prevent  inflammation,  bloodletting  (hould  be 
prefcribed  in  fuch  quantities  as  his  ftrength  will  bear  ; 
his  bowels  (hould  be  opened  with  proper  laxatives  j 
and  he  (hould  be  confined  to  a  low  regimen. 


SECTION     VI. 

Of  Luxations  of  the  Spine,  Os  Sacrum,  and  Os  Coccyx, 

THE  vertebrae,  or  bones  of  which  the  fpine  is  com- 
pofed,  are  fo  intimately  connected,  by  the  pro- 
cefs  ot  one  bone  running  into  correfponding  parts  of 
Vol.  III.  C  c 


403  Of  Luxations  of  ihi  Chap.  XL«, 

another,  as  well  as  by  flrong  ligaments  and  mufcles, 
that  they  are  feldom  diflocated.  They  are  fo  firmly 
united  indeed,  that  I  do  not  fuppofe  that  any  of  them 
can  be  diflocated  by  external  violence  without  being 
fractured.  Befides  the  means  of  connection  that  I 
have  mentioned,  the  vertebras  of  the  back  are  much 
ftrengthened  by  the  fupport  which  they  receive  frbm 
the  ribs. 

I  never  met  with  a  complete  diflocation  of  any  of 
the  vertebra  ;  nor  do  I  fuppofe  that  it  ever  happens, 
even  when  accompanied  with  a  fradlure,  but  with  im- 
mediate death  :  for  the  force  neceifary  to  move  one  of 
the  vertebrae  from  its  fituation,  muft  not  only  be  at- 
tended with  the  compreffion,  but  even  with  the  lacer- 
ation of  the  fpinal  marrow,  while  the  contents  of  the 
thorax  or  abdomen  mufl  in  a  very  eflential  manner 
be  hurt  by  it.  I  do  not  fuppofe,  therefore,  that  a 
complete  diflocation  of  any  of  thefe  bones  can  ever  be- 
come an  objeft  of  furgery. 

We  know,  however,  that  one  or  more  of  the  ver- 
tebrae may  be  partially  diflocated,  and  that  the  patient 
may  furvive.  In  fome  cafes,  perhaps,  a  complete  cure 
may  be  obtained ;  but  I  believe  that  it  does  not  fre- 
quently happen. 

Thefe  luxations  are  ufually  produced  by  falls  from 
great  heights  ;  by  violent  blows  j  or  by  heavy  weights 
pafling  over  the  body. 

They  are  diftinguifhed,  by  the  body  being  diftorted, 
by  examination  with  the  fingers,  and  by  the  fymptoms 
which  they  induce  ;  which  are  fuch  as  ufually  occur 
from  compreflion  of  the  fpinal  marrow  ;  particularly 
a  paralyfis  of  all  that  part  of  the  body  lying  beneath 
the  injured  part,  and  either  a  total  fuppreflion  of 
urine,  or  an  involuntary  pafling  of  both  urine  and 
faeces. 

There  Is  reafon  to  fuppofe,  from  the  niechanifm  of 
the  parts,  that  the  vertebrae  will  feldom  or  never  be 
diflocated  outwards :  they  are  ufually  forced  direclly 
forward,  or  in  fome  degree  to  the  right  or  left.     On 


Se6i:.  VL  Spine,  Os  Sacrum,  &c.  403 

this  account  they  are  extremely  difficult  to  reduce,  as 
the  contents  of  the  thorax  or  abdomen  muft  always 
lie  between  the  injured  parts  and  the  means  that  are 
ufcd  for  this  purpofe. 

Various  means  have  been  propofed,  and  different 
machines  invented,  for  the  redudion  of  diflocated  ver- 
tebrae. Thefe  machines,  however,  fliould  be  laid  afide, 
as  being  not  only  ufelefs,  but  dangerous  ;  for  whoev- 
er has  paid  attention  to  the  anatomy  of  the  fpine,  will 
fee,  that  in  diflocations  of  the  vertebrae,  fcarcely  any 
advantage  is  to  be  gained  from  the  application  of  much 
force,  while  much  mifchief  may  evidently  enfue  from 
it. 

When  one  or  more  of  the  vertebrae  are  luxated  for- 
ward, of  which  we  can  only  judge  by  an  accurate  ex- 
amination with  the  fingers,  the  mofl  certain  method, 
perhaps,  of  reducing  the  difplaced  bones  is,  to  bend 
the  body  flowly  and  gradually  forward,  as  far  as  it  can 
be  done,  over  a  calk,  or  any  other  cylindrical  fubftance 
of  a  fufficient  fize.  If  the  bone  by  this  pofition  re- 
gains its  fituation,  the  body  fhould  be  immediately 
raifed  ;  while  the  attempt  may  be  repeated  when  it 
does  not  fucceed  at  firft. 

When  the  difplaced  bone  is  pufhed  much  out  of  its 
natural  fituation,  neither  this  nor  any  other  method 
will  probably  fucceed  ;  but  it  has  certainly  done  fo  in. 
different  inftances  of  partial  diflocations.  In  bending 
the  body  forward,  the  two  vertebras  lying  contiguous 
to  the  one  that  is  puflied  forw^ard  are  fomewhat  farther 
feparated  from  each  other  ;  by  which,  the  difplaced 
bone  may,  either  by  the  compreffion  produced  upon 
the  abdomen,  or  by  the  ordinary  adion  of  the  contig- 
uous mufcles,  be  forced  into  the  fituation  that  it  form- 
erly occupied. 

When  the  diflocated  bone,  inftead  of  being  puflied 

flraight  forward,  is  forced  in  any  degree  to  one  fide, 

the  body  while  the  redudion  is  attempting,  fliould  not 

only  be  bent  forward,  but  fomewhat  towards  the  af- 

c  c  2 


404  Of  Liisailcns  Chap.  XL# 

feded  fide ;  by  which,  the  two  contiguous  vertebrce 
will  be  feparated  to  a  greater  diftance  than  they  pofli- 
bly  could  be  by  bending  it  either  diredly  forward  or 
towards  the  oppofite  fide. 

When  any  part  of  the  os  facrum  is  luxated,  all  that 
can  be  done  is  to  replace  it  with  as  much  exaflnefs  as 
poffible  by  external  preifure,  and  by  bending  the  body 
forward  in  the  manner  I  have  mentioned. 

The  coccyx  is  more  frequently  luxated  than  any 
of  thefe  bones,  as  it  is  equally  liable  to  the  fame  kinds 
of  injuries,  befides  being  more  expofed  to  the  effects 
of  falls,  and  to  be  injured  in  delivery. 

This  bone  may  be  luxated  either  outwardly  or  in- 
wardly. It  is  apt  to  be  forced  outwards  in  laborious 
births  when  much  violence  is  ufed  in  pulling  down 
the  head  of  a  child  ;  and  it  has  alfo  been  clifplaced  by 
large  colledtions  of  hard  f^aeces  in  the  reclum.  We 
judge  of  this  having  happened,  from  the  pain  which 
takes  place  all  over  the  region  of  the  loins,  particular- 
ly about  the  junftion  of  the  os  coccyx  with  the  facrum ; 
and  from  the  difplaced  bone  being  difcovered  upon 
examination  with  the  fingers. 

When  the  coccyx  is  luxated  inwardly  either  by  falls 
or  blows,  the  patient  complains  of  much  pain,  and  of 
the  fenfation  of  a  tumor  or  fome  other  hard  body  com- 
preffing  the  under  part  of  the  rectum  ;  he  is  hable  to 
tenefmus  ;  he  finds  it  difficult  to  pafs  his  fseces  ;  and 
in  fome  inflances,  a  fuppreflion  of  urine  takes  place. 
On  the  finger  being  introduced  at  the  anus,  the  dif- 
placed portion  of  bone  is  readily  difcovered. 

In  outward  luxations  of  the  coccyx,  we  feldom  find 
it  difficult  to  replace  the  bone  by  external  preffure  with 
the  fingers  ;  but  it  is  often  difficult  to  retain  it  in  its 
fituation.  It  can  only  be  done  by  fupporting  the  parts 
with  proper  comprelfes  and  bandages,  for  which  pur- 
pofe  the  T  bandage  anfwers  better  than  any  other. 

In  the  redu6lion  of  an  internal  diflocation  of  this 
bone,  the  forefinger -of  one  hand,  after  being  immerf* 
ed  in  oil,  Ihould  be  paffed  as  far  as  poflible  up  the  rec- 


Se£l.  VII.  of  the  Clavicks,  405 

turn.  By  means  of  it  the  bone  fhould  be  prefled  into 
its  fituation  ;  while  with  the  other  hand  we  fupport 
the  parts  outwardly  that  correfpond  with  it. 

As  diflocations  of  thefe  bones,  particularly  of  the 
coccyx,  are  very  apt  to  excite  inflammation^  and  as 
this  often  terminates  in  abfceffes  that  do  not  readily 
heal,  we  fliould  omit  nothing  that  may  probably  tend 
to  prevent  it.  Bloodletting  fliould  be  prefcribed  in 
proportion  to  the  ftrength  of  the  patient,  particularly 
local  bloodletting  with  leeches,  or  cupping  and  fcari- 
fying  ;  a  lax  flate  of  the  bowels  fhould  be  preferved  ; 
and  the  patient  fliould  be  confined  to  that  poflure  in 
which  he  is  eafiefl,  and  to  a  low  regimen. 


SECTION    VIL 
Of  Luxatio7is  of  the  Clavicles, 

THE-  clavicles  are  joined  to  the  fcapula  at  the  ac- 
romion, where  they  give  confiderable  fupport  to 
the  joint  of  the  flioulder  ;  and  their  interior  ends  are 
fupported  by  the  upper  part  of  the  ftemum. 

As  the  clavicles  are  not  pofTeffed  of  much  flrength, 
and  being  tied  at  their  articulations  to  the  contiguous 
bones  by  ligaments,  they  are  more  expofed  to  frac- 
tures than  to  luxations.  In  fome  cafes,  however,  they 
are  luxated.  This  may  happen  at  either  extremity  of 
thefe  bones,  but  it  is  more  frequent  at  their  jundion 
with  the  flernum  than  at  the  acromion  ;  for  the  force 
by  which  luxations  of  the  clavicles  are  produced,  is 
for  the  mofl  part  applied  to  the  fhoulders,  by  which 
their  oppofite  ends  are  mofl  apt  to  be  pufhed  out. 

As  the  clavicles  are  thinly  covered,  luxations  of  ei-* 
ther  of  their  extremities  are  eafily  difcovered  :  they 
commonly  produce  a  good  deal  of  flifihefs  and  immo- 
bility in  the  correfponding  joint  of  the  flioulder  j  for 
the  neck  of  the  fcapula  having  lofl  its  fupport,  it  is  apt 


4o6  Of  Lnxatiom  Chap.  XL, 

to  be  drawn  out  of  its  fituation  ;  by  which  the  motion 
of  every  mufcle  connected  with  the  joint  is  necefl'arily 
affected. 

A  diflocation  of  the  clavicle  is  eafily  reduced  by 
moderate  prelfure  with  the  fingers,  efpecially  if  the 
arms  and  fliouldcrs  are  at  the  fame  time  drawn  back ; 
by  which  the  fpace  which  the  clavicle  Ihould  occupy 
may  be  fomewhat  lengthened.  It  is  more  difficult, 
however,  to  retain  the  bone  in  its  fituation,  as  it  is  apt 
to  be  again  difplaced  on  the  preffure  being  removed, 
by  the  ordinary  action  of  the  flexor  mufcles  of  the 
arm. 

We  derive  little  advantage  here  from  fupporting  the 
arm.  On  the  contrary,  when  the  end  of  the  clavicle 
connected  with  the  fternum  is  difplaced,  raifmg  the 
arm  does  harm,  as  it  tends  to  pufh  the  bone  farther 
out  of  its  place.  It  is,  therefore,  highly  necefi'ary  to 
attend  to  this  difference  between  the  management  of 
fra£tures  and  luxations  of  this  bone.  In  the  latter,  an 
elevated  pofture  of  the  arm  does  mifchief :  in  the  form- 
er, it  proves  ufeful,  as  I  have  fhewn  in  Chapter 
XXXIX.  Seaion  V. 

The  weight  of  the  fore-arm  ought  however  to  be 
moderately  fupported  to  prevent  the  flioulder  from 
being  too  much  drawn  down.  Befides  this,  the  head 
and  ftioulders  fhould  be  fupported,  and  a  moderate 
preffure  made  upon  the  difplaced  end  of  the  bone. 
Various  bandages  have  been  propofed  for  this,  partic- 
ularly the  long  roller  applied  in  fuch  a  manner  as  to 
form  the  figure  of  8  upon  the  fhoulders  and  upper 
part  of  the  breaft.  No  advantage,  hov/ever,  iS  gained 
from  this,  as  the  bandage  cannot  be  retained  fo  firm-^ 
ly  in  its  fituation  as  to  have  any  effedt  without  imped- 
ing refpiration.  The  machine  reprefented  in  Plate 
CI.  fig.  I.  nearly  the  fame  as  is  commonly  ufed  for 
fupporting  the  head,  anfwers  the  purpofe  better  than 
any  other ;  for  while  it  neceffarily  raifes  the  head  and 
keeps  the  fhoulders  back,  the  flraps  that  pafs  over  the 
upper  part  of  the  breafl  may  be  made  to  a6t  with  fome 


Sea.  VIII.  of  the  Ribs.  407 

force  upon  the  diflocated  end  of  the  bone.  It  is  fcarce- 
ly  necelTary  to  obferve,  that  the  ufe  of  this  machine 
rfiould  be  continued  for  a  confiderable  time,  otherwife 
the  bone  is  apt  to  ftart,  when  the  whole  is  to  do  over 
again. 


SECTION    VIII. 
Of  Luxations  of  the  Ribs, 


BY  many  it  has  been  fuppofed  that  the  ribs  cannot 
be  diflocated ;  and  accordingly  this  variety  of 
luxation  has  pafled  unnoticed  by  different  writers  on 
this  branch  of  furgery.  It  is  only  at  the  articulation 
of  th^ribs  with  the  vertebrae  that  luxations  can  hap- 
pen ;  and  being  conneded  with  thefe  bones  by  ftrong 
ligaments,  they  more  frequently  break  than  yield  at 
the  joints. 

It  will  readily,  however,  appear,  by  accurate  exami- 
nation of  the  jundion  of  the  ribs  with  the  vertebras, 
that  they  may  be  diflocated  inwards.  They  cannot 
indeed  be  pufhed  either  upwards,  downwards,  or  back- 
wards ;  but  we  know  from  experience,  that  a  ftrong 
force  applied  near  to  their  articulations,  will  rupture 
their  conneding  ligaments,  and  thus  pufli  them  for- 
ward ;  for  the  fad  has  been  proved  by  diflfedion  after 
death. 

The  fymptoms  induced  by  diflocations  will  be  near- 
ly the  fame  with  thofe  that  enfue  from  fradures  of 
the  ribs,  namely,  pain  in  the  injured  part,  with  diffi- 
cult refpiration  ;  and  if  the  end  of  the  bone  is  puflied 
into  the  fubftance  of  the  lungs,  emphyfematous  fvvell- 
ings  may  enfue  from  it.  A  diflocation,  however,  may 
be  diftinguiflied  from  a  fradure,  by  the  pain  being 
mofl:  fevere  at  the  articulation,  and  by  no  part  of  the 
bone  yielding  to  prefl'ure  excepting  at  this  very  fpot. 


4o8  Of  Lvxatiom^  &c.  Chap.  XL. 

I  believe  It  will  commonly  happen,  that  the  end  of 
a  luxated  rib,  in  confequence  of  its  elaflicit)^,  wiil  re- 
turn to  its  natural  fituation  when  the  caufe  by  which 
the  luxation  was  produced  is  removed ;  but  when  it 
does  not,  the  bed  method  of  reducing  it  will  be  to 
bend  the  body  forward  over  a  cafli  or  other  cylindri- 
cal body,  while  the  vertebrae  immediately  above  and 
below  the  rib  are  prefled  inward  with  as  much  force 
as  can  with  fafety  be  applied  to  them.  After  this,  a 
thick  comprefs  of  linen  fliould  be  laid  over  thefe  ver- 
tebras, and  another  long  one  along  the  moft  promi- 
nent part  of  the  diflocated  rib  and  the  two  ribs  imme- 
diately contiguous  J  when,  by  means  of  a  long  broad 
l*oller  paffed  two  or  three  times  round  the  body,  fo 
much  prefTure  may  be  made  upon  the  vertebree  as  will 
retain  them  in  their  fituation  ;  while  the  prelfure  made 
upon  the  projecting  part  of  the  rib  tends  to  ke^  the 
end  of  It  in  its  fituation  till  the  ligaments  that  were 
ruptured  are  again  united. 

No  bandage  fhould  be  applied  with  fuch  tightnefs 
as  to  impede  the  breathing.  The  beft  method  of  pre- 
venting the  roller  from  moving,  is  by  the  fcapulary 
bandage  paifed  over  the  fhoulder,  and  a  ftrap  con- 
ne£ted  with  it  behind,  carried  behind  the  thighs  and 
fixed  to  it  before. 

No  diilocation  Is  more  apt  to  Induce  Inflammation 
of  the  contiguous  parts,  and  other  difagreeable  fymp- 
toms  ;  for  the  prevention  and  removal  of  which,  noth- 
ing anfwers  fo  well  as  copious  bloodletting,  preferving 
the  patient  cool,  and  at  perfect  reft,  a  low  diet,  gentle 
laxatives,  and  opiates  if  a  cough  enfues  and  becomes 
troublefome. 


Secb.  IX.  Of  Dlflocaiions^  &c.  409 


SECTION    IX. 

Of  Diflocations  of  the  Humerus  at  the  Joint  of  the 
Shoulder. 

THE  joint  of  the  fhoulder  is  formed  by  what  is 
ufually  termed  a  ball  and  focket,  the  round  head 
of  the  OS  humeri  being  lodijjed  in  a  cavity  on  the  an- 
terior part  of  the  fcapula.  This  cavity,  however,  is  fo 
fuperficial,  that  in  the  ikeleton  it  does  not  appear  to 
contain  above  a  tenth  part  of  the  head  of  the  hume- 
rus J  but  in  the  recent  fubject  it  is  much  more  con- 
fiderable,  by  means  of  a  cartilaginous  brim ;  and  a 
capfular  ligament  furrounds  the  whole  joint.  By  this 
mechanifm,  the  flioulder  enjoys  more  free  motion  than 
other  joints ;  but  by  this  it  is  alfo  expofed  to  more 
frequent  luxations ;  infomuch,  that  we  meet  with 
more  diflocations  of  the  flioulder  than  of  all  the  other 
joints  of  the  body. 

The  OS  humeri  is  mofi:  frequently  luxated  down- 
wards dlredly  into  the  axilla,  owing  to  the  head  of 
the  bone  meeting  with  lefs  refiftance  in  falling  into 
tliis  fituation  than  in  any  other  direction.  The  head 
of  the  bone  is  fometimes  pufhed  downwards  and  for- 
vard,  and  lodged  beneath  the  peroral  mufcle,  when 
we  find  it  refling  on  the  ribs  between  the  coracoid 
procefs  of  the  fcapula  and  the  middle  of  the  corre- 
sponding clavicle.  In  a  few  cafes  it  is  diflocated  down- 
wards and  backwards  :  but  it  can  never  be  luxated 
upwards  without  being  accompanied  with  a  frafture 
of  the  acromion  j  of  the  coracoid  procefs ;  or  perhaps 
of  both. 

The  head  of  the  bone,  as  I  have  already  obfen'ed, 
takes  for  the  mod  part  that  direction  in  which  it  meets 
with  the  leaft  refiftance  ;  but  this  alfo  depends  in  feme 
degree  on  other  caufes,  particularly  on  the  part  of  the 
joint  which  received  the  injury,  and  on  the  fituation 


41  o  Of  Dijlocatiom  of  the  Chap,  XL. 

of  the  humerus  at  the  time.  Thus,  if  a  blow  falls 
upon  the  upper  part  of  the  joint,  while  the  arm  is  in 
a  direft  line  with  the  body,  any  diflocation  that  takes 
place  will  be  downwards ;  while  the  head  of  the  bone 
will  moft  probably  be  forced  downward  and  inward 
by  any  ftroke  given  to  the  outfide  of  the  joint  while 
the  elbow  is  flretched  back,  and  vice  versa. 

We  judge  that  the  humerus  is  difplaced  by  the  pa- 
tient being  unable  to  move  the  arm  ;  by  pain  being 
excited  on  every  attempt  to  prefs  the  arm  near  to  the 
fide  ;  by  the  arm  being  of  a  different  length  from  the 
other  ;  from  its  being  longer  or  fliorter  according  as 
the  head  of  the  bone  is  lower  or  higher  than  its  nat- 
ural fituation  in  the  acetebulum  ifcapulae  ;  by  the 
head  of  the  bone  being  felt  either  in  the  armpit,  be- 
neath the  perioral  mufcle,  or  backwards  below  the 
ridge  of  the  fcapula  ;  and  by  a  vacancy  being  difcov- 
ered  beneath  the  acromion.  If  the  two  fhoulders  are 
examined  together,  which  fhould  always  be  done,  the 
found  joint  will  be  found  round  and  prominent,  while 
the  forepart  of  the  other,  if  much  tumefadion  has  not 
taken  place,  will  appear  to  be  fiat,  or  even  fomewhat 
hollow.  This  difference  in  appearance  between  the 
two  joints  appears  moft  obviouily  on  viewing  them 
both  from  above  downwards. 

In  luxations  of  long  duration,  the  whole  arm  is  apt 
to  become  oedematous,  and  to  be  in  fome  degree  de- 
prived of  fenfibility,  from  the  preffure  produced  upon 
the  nerves  and  lymphatic  veffels  of  the  arm  by  the 
head  of  the  bone.  All  the  other  appearances  I  have 
mentioned,  are  likewife  fo  obvioufly  induced  by  the 
difplacement  of  the  head  of  the  humerus,  that  fcarcely 
any  of  them  require  to  be  explained.  The  head  of 
the  bone  being  thrown  out  of  its  natural  fituation, 
muff  neceffarily  affocl  the  aftion  of  every  mufcle  of 
the  joint :  fome  will  be  too  much  relaxed,  while  oth- 
ers are  overftretched  :  the  motion  of  the  joint  mufl 
of  courfe  be  confiderably  impaired.  It  is  obvious  too, 
that  much  pain  muft  be  excited  by  the  arm  being 


Seel.  IX.  Joint  of  the  Shoulder.  41 1 

prefled  down  to  the  fide,  as  the  head  of  the  bone  will 
not  only  be  forcibly  rubbed  againft  fome  part  of  the 
fcapula,  but  the  foft  parts  on  which  it  refts  muft  be 
greatly  compreffed,  at  the  fame  time  that  fome  of  the 
contiguous  mufcles  will  be  ftretched  to  a  degree 
which  they  cannot  eafily  bear. 

In  a  fimple  diflocation  of  the  humerus,  our  prog- 
nofis  fhould  in  general  be  favourable  ;  for  in  recent 
cafes  we  feldom  fail  in  the  reduction  of  the  bone.  In- 
ftances  not  unfrequently  however  occur,  in  which  the 
operation  is  difficult ;  but  this  is  feldom  the  cafe  where 
it  has  been  properly  conduced  from  the  firfl.  In  dif- 
locations,  indeed,  of  long  continuance,  the  mofl  ex- 
pert praditioners  often  fail  ;  for  in  fuch  cafes,  the 
head  of  the  bone  has  often  formed  a  focket  among 
the  contiguous  parts,  from  whence  it  cannot  be  dii- 
lodged  without  tearing  afunder  fome  of  the  mufcles 
with  which  it  is  furrounded  ;  and  when  diflodged, 
our  endeavours  may  be  rendered  abortive,  by  the  ca- 
vity in  which  the  bone  (hould  be  lodged  being  dimin- 
ilhed.  In  all  cafes,  therefore,  of  long  duration,  that 
is,  where  the  bone  has  been  out  of  its  place  for  fix 
months  or  upwards  ;  for  I  have  often  fucceeded  where 
it  has  been  out  two,  three,  and  even  four  months  ; 
although  it  may  be  proper  to  make  fome  attempts  to 
replace  the  dillocated  bones,  yet  none  that  require 
great  force  fliould  be  much  perfiflied  in,  for  the  at- 
tempt muft  always  be  of  uncertain  fuccefs,  while  it 
neceffarily  gives  a  great  deal  of  pain,  at  the  fame  time 
that  it  is  apt  to  render  the  motion  of  the  head  of  the 
bone  in  the  artificial  focket,  which  it  generally  forms 
for  itfelf,  more  fi:iff  than  it  was  before. 

In  general  it  is  fuppofed,  that  the  humerus  is  more 
eafily  reduced  when  the  head  of  the  bone  is  lodged 
in  the  axilla  than  when  it  is  pufhed  forward  beneath 
the  peftoral  mufcle ;  but  more  eafily  when  lodged 
beneath  this  mufcle  than  where  it  is  forced  back  be- 
neath the  fpine  of  the  fcapula.     The  latter  I  believe 


412  Of  Di/Jocaiions  cfihe  Chap.  XL. 

to  be  fo  ;  but  I  have  not  found  in  the  treatment  of 
the  others  that  there  is  any  difference  between  them. 

In  the  redudion  of  a  diflocated  humerus^  we  are  in 
general  told,  that  it  is  to  be  done  by  extenfion,  coun- 
ter extenfion,  and  the  fubfequent  application  of  fuch 
a  force  as  is  fufficient  to  replace  the  bone.  Thefe 
three  indications,  however,  may  all  be  comprehended 
in  one.  If  a  fufficient  degree  of  extenfion  is  applied 
for  dravt'ing  the  head  of  the  bone  on  a  line  with  the 
acetabulum,  the  furgeon  will  feldom  have  any  thing 
farther  to  do ;  for  when  brought  to  this  fituation,  the 
reduction  is  almofb  in  every  inftance  inflantly  com- 
pleted by  the  ordinary  action  of  the  mufcles. 

All  that  we  have  to  do  by  counter  extenfion,  is  to 
fix  the  body  fteadily  while  the  arm  is  extending,  and 
to  prevent  the  fcapula  from  being  drawn  forward  by 
the  force  that  is  necefllu-y  for  moving  the  arm  ;  for  if 
this  bone  be  not  fixed,  it  in  fome  degi-ee  moves  for- 
ward with  the  humerus,  by  which  the  force  employed 
for  extending  the  arm  is  in  fome  meafure  loft,  at  the 
fame  time  that  the  cavity  in  the  fcapula  in  which  the 
head  of  the  bone  is  to  be  placed,  is  thus  kept  in  a 
ftate  of  motion,  by  which  the  redudtion  cannot  be  fo 
readily  effe£ted. 

This  being  done,  our  powers  of  extenfion  are  ap- 
plied to  the  arm,  till  the  head  of  the  bone  is  drawn  on 
a  line  with  the  brim  of  the  focket ;  when,  as  I  have 
obferved  above,  it  will  inftantaneoufly  flip  into  its  place 
by  the  adion  of  the  contiguous  mufcles  ;  fo  that  there 
is  no  neceffity  for  the  appHcation  of  any  force  for  this 
purpofe.  Much  mifchief  has  often  been  done  by  force 
applied  with  this  view,  as  we  fhall  prefently  fee  on 
confidering  the  different  modes  of  reducing  luxations 
of  this  joint ;  for  it  is  obvious,  if  the  force  that  is  ufed 
for  raifing  the  humerus  is  applied  before  the  end  of  it 
is  drawn  pafl  the  mofi  projeding  point  of  the  fcapula, 
that  the  two  bones  mufl  be  thus  preffed  together  fo 
as  to  obftruft  the  redudion. 


Sea.  IX.  John  of  the  Shoulder.  413 

Various  modes  have  been  propofcd  for  the  reduc- 
tion of  diflocatcd  fhoulJers,  infomuch  that  we  feldom 
meet  with  two  praciitioners  who  do  it  in  the  fame 
manner  :  but  as  one  or  other  of  thefe  mufl  be  prefer- 
able to  the  reft,  and  as  it  is  of  much  importance  to 
have  this  afcertained,  I  Ihall  offer  a  few  obfervations 
upon  each  of  them,  and  fhall  more  particularly  de- 
fcribe  that  which  to  me  appears  to  be  the  beft. 

I.  The  humerus  is  often  reduced  by  preilure  with 
the  heel  upon  the  head  of  the  difplaced^  bone.  The 
patient  being  placed  upon  the  floor,  the  furgeon  alfo 
fitting  upon  the  floor  directly  before  him,  puts  the  heel 
of  one  foot,  that  of  the  left  foot  when  he  is  operating 
upon  the  left  flioulder,  and  vice  versa,  upon  the  head 
of  the  bone ;  and  laying  hold  of  the  fore-arm  with 
both  hands,  he  extends  the  arm,  at  the  fame  time  that 
he  endeavours  with  his  heel  to  pufh  up  the  bone. 

When  the  head  of  the  bone  has  fallen  dire6lly 
downward  into  the  armpit,  we  are  direded  by  fome 
to  place  a  fmall  tennis  ball  or  any  other  round  fub- 
ftance  between  it  and  the  heel ;  by  which  the  preffure 
may  be  continued  with  more  certainty  into  the  bottom 
of  the  axilla  than  where  the  heel  alone  is  employed. 

This  method,  however,  is  liable  to  three  very  im- 
portant objedions.  By  laying  hold  of  the  fore-arm, 
the  joint  of  the  elbow  is  confiderably  ftretched,  by 
\vhich  it  may  be  much  hurt,  while  a  great  part  of  the 
force  is  fpent  upon  it  which  ought  to  have  been  ap- 
plied entirely  to  the  os  humeri :  by  extending  the 
fore-arm,  feveral  of  the  mufcles  of  the  arm  itfelf,  as 
well  as  the  biceps  flexor  cubiti,  are  put  upon  the 
ftretch ;  by  which  the  extenfion  is  rendered  much 
more  difficult  than  when  thefe  mufcles  are  relaxed  by 
the  joint  of  the  elbow  being  properly  bent.  And, 
lallly,  whether  the  heel  be  employed  by  itfelf  or  with 
a  ball,  it  is  much  more  apt  to  do  harm  than  good  ; 
for  if  it  be  not  applied  with  fuch  nicety  and  exadnefs, 
as  to  pufli  the  head  of  the  bone  directly  tov.ards  the 
fockct,  it  mud  neceffarily  force  it  againlt  the  neck  of. 


414  OfDiJlocat'ions  of  the  Chap.  XL. 

the  fcapula  or  fome  of  the  contiguous  parts,  and  will 
thus  tend  in  the  mofh  effeclual  manner  to  counteradt 
the  extenfion  of  the  arm. 

Befides,  in  this  manner,  the  arm  mud  in  every  in- 
flance  be  pulled  in  a  verj'^  oblique  direction  downwards 
by  the  relative  fituation  of  the  furgeon  and  patient ; 
whereas  it  fhould  in  fome  cafes  be  raifed  nearly,  though 
not  entirely,  to  a  right  angle  with  the  body,  and  kept 
in  that  pofition  while  the  extenfion  is  going  on. 

It  may  be  alleged,  indeed,  that  this  method  often 
fucceeds,  and  that  it  has  long  been  employed  by  fome 
of  our  oldeft  and  moft  experienced  furgeons.  This  I 
admit :  but  I  alfo  know  that  it  often  fails,  even  with 
thofe  who  fpeak  mod  favourably  of  it ;  and  that  oth- 
er modes  of  treatment  have  in  various  inftanccs  an- 
fwered,  where  this  had  previoufly  failed. 

2.  Others  attempt  to  reduce  this  diflocation,  by  en- 
deavouringr  to  force  the  head  of  the  bone  into  the 
focket  with  a  rolling-pin  applied  beneath  it,  while  a 
fufficient  force  is  employed  for  extending  the  arm,  and 
for  fixing  the  body  in  its  fituation.  With  a  view  to 
prevent  the  pin  from  hurting  the  fkin,  we  are  defired 
to  cover  it  with  flannel,  and  that  part  of  it  which  pafl- 
es  into  the  axilla  is  directed  to  be  more  thickly  cov- 
ered than  the  reft. 

But  however  this  may  in  fome  inftances  fucceed,  it 
ought  by  no  means  to  be  received  into  pra6lice.  It 
is  evidently  liable  to  moft  of  the  objections  I  have 
mentioned  to  the  mode  of  operating  with  the  heel ; 
particularly  to  the  rifl^  of  forcing  the  head  of  the  hu- 
merus in  beneath  the  neck  of  the  fcapula,  and  thus 
counteracting  the  force  employed  for  extending  the 
arm.  It  is  obvious,  too,  even  on  the  principle  upon 
which  it  is  recommended  by  thofe  who  pra6tife  it,  that 
this,  as  well  as  the  mode  of  operating  with  the  heel, 
cannot  be  applicable  where  the  head  of  the  bone  is 
lodged  either  backward,  or  forward  beneath  the  pec- 
toral mufcle  :  for  the  fole  Intention  of  both  is  to  raifc 
the  head  of  the  bone  ;  and  yet  by  fome  they  are  ufed 


Sedt.  IX.  Joint  of  the  Shoulder.  415 

indifcriminately,  whether  the  bone  is  luxated  down- 
wards, backwards,  or  forward. 

3.  The  patient  being  properly  placed,  the  body  fix- 
ed by  ailiflants,  and  the  arm  extended  in  the  manner 
I  fhall  afterwards  direct,  fome  furgeons  make  ufe  of  a 
towel  or  girth  for  pulling  the  head  of  the  bone  into 
the  focket.  The  ends  of  the  girth  being  tied  togeth- 
er, one  end  of  the  double  is  put  over  the  arm,  and 
carried  near  to  the  head  of  the  humerus  ;  and  the  oth- 
er being  pafTed  over  the  neck  of  the  operator,  he  forc- 
es up  the  end  of  the  bone  by  raifnig  his  neck  ;  and  if 
this  could  be  done  with  fufficicnt  exaftnefs,  jufl  when 
the  head  of  the  humerus  has  cleared  the  brim  of  the 
focket,  no  harm  would  arife  from  this  part  of  the  op- 
eration ;  but  if  the  force  for  elevating  the  bone  be  ap- 
plied before  a  fufficient  degree  of  extcnfion  is  made 
for  this  purpofe,  it  muft  evidently  do  mifchief,  by 
locking  the  head  of  the  humerus  and  neck  of  the  fca- 
pula  together  :  fo  that  this  is  in  fome  meafure  liable 
to  the  fame  objedions  that  I  have  Hated  to  the  mode 
of  operating  with  the  heel  and  rolling-pin. 

Thefe  were  the  means  ufually  employed  for  reduc- 
ing luxations  of  this  joint ;  but  being  frequently  found 
to  fail,  others  have  at  different  times  been  propofed  in 
order  to  increafe  the  powers  of  extenfion. 

4.  Of  this  nature  is  the  ambe  of  Hippocrates,  as 
it  is  ufually  termed  :  it  is  the  one  that  was  chiefly  em- 
ployed by  ancient  praditioners,  and  in  fome  parts  of 
Europe  it  is  ftill  the  only  inftrument  ufed  for  this  pur- 
pofe :  for  this  reafon  I  have  given  a  delineation  of  it 
in  Plate  LXXXVII.  fig.  i.  but  I  do  not  by  any  means 
advife  it  to  be  employed.  The  powers  of  which  it  is 
pofleffed  arc  great,  but  they  cannot  be  properly  appli- 
ed ;  fo  that  they  are  pernicious  in  proportion  to  their 
extent.  It  is  hable  in  a  tenfold  degree  to  the  objec- 
tion I  have  Hated  above  to  the  three  preceding  modes 
of  reducing  this  bone,  that  of  prefling  the  head  of  it 
againft  the  neck  of  the  fcapula  ;  by  which  one  or  oth- 
er of  them  muft  frequently  be  broken,  as  will  readily 


41 6  Of  Dijlocaiions  cf  the  Chap.  XL, 

occur  to  whoever  examines  this  inftrument  with  at- 
tention ;  for  initead  of  extending  the  arm  before  raif- 
ing  the  end  of  it,  the  firll  action  of  this  inftrument  is 
to  raife  the  extremity  of  the  bone,  by  which  it  mufl 
be  fo  firmly  pufncd  in  beneath  the  neck  of  the  fcapu- 
la,  as  to  counterad  with  much  effeft  the  power  after- 
wards apphed  to  extend  it. 

5.  The  method  of  reducing  this  joint  by  means  of 
a  ladder  has  been  long  known,  but  I  hope  not  often 
employed.  The  diflocated  arm  being  hung  over  the 
upper  flep  of  the  ladder,  to  which  height  the  patient 
mufl  be  previoufly  raifed,  and  being  fecured  in  this 
fituation  by  afliftants,  the  feat  on  which  he  is  placed 
is  fuddenly  drawn  away ;  by  which  the  whole  weight 
of  the  body  falls  upon  the  luxated  joint  and  by  vv'hich 
we  are  told  the  bone  may  often  be  reduced  when  oth- 
er means  have  failed.  The  top  of  a  high  door  is  fome- 
times  ufed  for  the  fame  purpofe.  ^Vhether  the  door 
or  ladder  is  employed,  that  part  upon  which  the  arm 
is  made  to  reft  fhould  be  well  covered  with  feveral 
pHes  of  foft  cloth  or  flannel. 

6.  The  patient  being  laid  upon  the  floor,  the  bone 
has  in  fome  inflances  been  reduced  by  two  or  three 
flout  men  flanding  upon  a  table,  and  lifting  him  fud- 
denly up  by  the  luxated  arm. 

7.  Upon  the  fame  principle,  it  has  been  propofed 
to  raife  the  patient  by  the  luxated  arm  with  ropes 
running  over  puUies  fixed  in  the  ceiling  of  a  high 
roofed  apartment.  The  jerk  produced  by  the  body 
being  fuddenly  raifed  and  let  down,  has  in  fome  cafes 
fucceeded  where  other  attempts  to  reduce  the  hume- 
rus had  failed. 

This  was  firft  praftifed,  I  believe,  by  the  ingenious 
Mr.  White,  of  Manchefler  ;  and  I  have  known  it  fuc- 
ceed  in  different  cafes  of  old  luxations  :  but  thefe  me- 
thods are  all  liable  to  great  objections.  The  force  is 
too  fuddenly  applied  ;  by  which  more  mifchief  may 
be  done  to  the  furrounding  foft  parts  than  can  be 
compenfatcd  by  the  redudion  of  the  bone.    We  know 


Sed.  IX.  Joint  of  the  Shoulder,  417 

that  mufcles,  blood  veflfels,  and  ligaments,  will  flretch 
to  a  confiderable  degree,  if  the  extending  force  be  ap- 
plied in  a  gradual  manner :  but  we  alfo  know,  that 
they  very  readily  break  when  powerfully  and  fudden- 
ly  ftretched.  C3f  this  we  have  a  remarkable  inftance 
in  the  burfting  of  the  capfular  ligaments  of  joints, 
which  I  believe  to  happen,  as  I  have  endeavoured  to 
fhew,  in  almoft  every  cafe  of  luxation  from  external 
violence.  This  leads  us  to  fay,  that  any  force  that  is 
ufed  for  the  redudion  of  luxations  fliould  be  applied 
in  the  mod  gradual  manner,  and  that  the  mode  of 
operating  we  are  now  confidering,  mufl  frequently  do 
harm  by  tearing  and  lacerating  the  foft  parts  furround- 
ing  the  joint.  Of  this  I  have  have  had  various  inflan- 
ces  even  where  the  teguments  have  been  protected  in 
the  mod  cautious  manner,  by  covering  them  with  foft 
flannel,  and  afterwards  with  fuin  leather,  before  ap- 
plying the  ropes  for  extending  the  arm. 

Befides,  in  rhefe  modes  of  redudlion,  the  arm  muft 
be  always  extended  in  the  fame  direction,  whether  the 
bone  be  luxated  forward,  downward,  or  backward : 
whereas  the  direction  in  which  the  arm  is  extended, 
fliould  vary  according  to  thefe  circumftances  ;  as  mull 
be  obvious  to  whoever  attends  to  the  anatomy  of  the 
parts  concerned  in  the  luxation.  Nay  in  one  variety 
of  luxation,  irreparable  mifchief  may  be  done  to  the 
joint,  by  extending  the  arm  in  a  direction  which,  in 
another,  might  not  only  be  proper,  but  neceflary. 
Where  the  head  of  the  humerus  is  puflied  forward  be- 
neath the  perioral  mufcle,  or  direclly  backward,  we 
may  readily  fuppofe  that  it  may  be  eafily  reduced  by 
pulling  the  arm  upward,  as  is  done  when  the  body  is 
fufpended  by  a  pully  in  the  manner  I  have  mention- 
ed ;  while  much  harm  may  be  done  by  it,  where  the 
head  of  the  bone  is  lodged  in  the  axilla,  and  puflied 
beneath  the  neck  of  the  fcapula.  In  this  cafe,  the 
end  of  the  humerus  is  often  fo  firmly  wedged  between 
the  fcapula  and  ribs,  that  one  or  other  of  thefe  bones 

Vol.  hi.  D  d 


41 8  Of  Dijlocatiom  of  the  Chap.  XL. 

would  neceflarily  break  by  the  fudden  application  of 
much  force  in  this  direction ;  and  it  can  only  be  pre- 
vented by  extending  the  arm  fomewhat  obliquely 
downward  till  the  head  of  the  humerus  is  quite  difen- 
gaged. 

8.  A  machine  has  been  invented  for  conjoining  the 
power  of  the  ambe,  with  the  mode  of  operating  we 
have  juft  been  confidering  ;  in  which  the  patient's 
body  is  nearly  fufpended  by  the  diflocated  arm,  and 
is  fuddenly  raifed  and  let  down  again  while  the  ope- 
rator endeavours  with  the  lever  of  the  ambe  to  elevate 
the  head  of  the  bone.  The  invention  is  ingenious, 
and  the  inftrument  is  evidently  powerful ;  but  if  our 
objedtions  to  thefe  two  modes  of  operating,  taken 
feparately,  are  well  founded,  they  are  no  lefs  fo  when 
they  are  combined.  The  powerful  action  of  the  lever 
muft  be  hazardous  in  proportion  to  the  uncertainty  of 
its  application.  While  the  body  is  quickly  rifmg  and 
falling,  the  lever  cannot  poflibly  be  applied  with  ex- 
aclnefs  to  the  end  of  the  bone  ;  and  if  made  to  a6t 
with  much  force  before  the  head  of  the  humerus  is 
cleared  of  the  fcapula,  one  or  other  of  thefe  muft  ne- 
celfarily  give  way. 

9.  When  the  more  fimple  methods  of  reducing 
luxations  have  failed,  ropes  and  pullies  have  fome- 
times  been  employed.  Of  thefe,  different  forms  may 
be  feen  in  Plate  LXXXVIII.  figure  1  ;  in  Scultetusj 
Plate  XXII.  fig.  I  ;  and  in  Plate  X.  fig.  7.  of  Defa- 
gulier's  Experimental  Philofophy.  With  one  or  oth- 
er of  thefe,  any  degree  of  force  may  be  applied  that 
can  ever  be  required  for  this  purpofe. 

10.  But  when  recent  cafes  are  properly  managed, 
luxations  may  in  almoft  every  inftance  be  reduced 
without  any  afTiftance  from  machinery.  I  often  fuc- 
ceed  by  the  moderate  extenfion  1  am  able  to  make  of 
the  arm  with  one  hand,  while  the  other  is  employed 
in  prefTmg  back  the  fcapula.  This,  however,  requires 
all  the  mufcles  of  the  arm  and  fore-arm  to  be  as  much 
relaxed  as  poffible  ;  which  we  accomplifh  by  bending 


Se£t.  IX.  yoint  of  the  Shoulder.  419 

the  elbow  moderately,  raifing  the  arm  to  a  height 
fomewhat  lefs  than  a  right  angle  with  the  body,  and 
preferving  it  in  fuch  a  diredion  as  to  prevent  either 
the  pectoral  or  extenfor  mufcles  of  the  arm  from  be- 
ing flrctched.  When  the  arm  is  in  this  fituation,  we 
often  find  luxations  eafily  reduced  which  had  previ- 
oufly  refilled  the  greatell  force  ;  for  in  this  manner 
we  not  only  relax  the  mufcles  of  the  arm,  but  the 
capfular  ligament  of  the  joint  ;  by  which  the  head  of 
the  bone  returns  more  readily  by  the  opening  at  which 
it  was  forced  out  than  it  otherwife  poffibly  could  do. 
For  when  the  ligament  is  much  ftretched,  it  will  grafp 
the  neck  of  the  bone,  by  which  our  being  able  to  re- 
turn it  will  necefl'arily  be  rendered  more  uncertain. 

More  force,  however,  is  fometimes  required  than 
can  be  applied  in  this  manner  ;  and  the  following  is 
a  method  by  which  I  have  never  yet  failed  in  recent 
luxations.  The  patient  is  feated  upon  a  chair,  and. 
his  body  fecured  by  a  long  broad  belt  pafled  round  it, 
and  given  to  alhllants,  or  tied  round  a  poll :  a  firm 
band  of  leather,  four  or  five  inches  broad,  and  lined 
with  flannel,  as  is  reprefented  in  Plate  LXXXVIII.  fig. 
3.  is  now  tied  round  the  arm  immediately  above  the 
elbow.  The  three  ftraps  or  cords  connected  with  this 
band  being  given  to  alllftants,  they  are  defired  to  ex- 
tend the  arm  in  the  relaxed  pofition  I  have  mentioned, 
and  in  a  flow  equal  manner,  while  another  afiiftant 
ftanding  behind  is  employed  in  keeping  the  fcapula 
firm.  The  furgeon  himfelf  (lands  moft  conveniently 
on  the  outfide  of  the  arm  :  his  bufinefs  is  to  dired:  the 
afTiflants  in  the  degree  of  force  they  are  to  employ, 
and  to  point  out  the  diredion  in  which  the  arm  is  to 
be  extended  ;  he  may  alio  fupport  the  fore-arm  and 
retain  it  bent  at  the  elbow,  in  the  manner  I  have  men- 
tioned. As  foon  as  the  head  of  the  bone  is  drawn 
clearly  pafl  the  brim  of  the  focket,  the  extenfion  of 
the  arm  fliould  be  fomewhat  relaxed,  when  the  re- 
dudion  will  for  the  moft  part  be  accompliflied  by  the 
£>  JD  2 


420  Of  DijOocaiions  of  the  Chap.  XL. 

action  of  the  mufcles  of  the  joint ;  or  it  will  be  readi- 
ly effected  by  moving  the  arm  gently  in  different  di- 
rections. A  crack  is  heard  on  the  bone  flipping  in  ; 
the  patient  finds  immediate  relief;  and  the  anterior 
part  of  the  fhoulder  acquires  its  ufual  prominent  form. 

The  diredion  in  which  the  arm  is  extended,  muft 
depend  upon  the  fituation  of  the  head  of  the  bone  : 
that  in  which  it  will  meet  with  the  leaft  refiftance  is 
always  to  be  preferred.  When  the  head  of  the  bone 
is  pufhed  forward,  and  lodged  beneath  the  pectoral 
mufcle,  the  arm  fnould  be  raifed  to  a  right  angle  with 
the  body,  and  the  fame  direftion  will  anfwer  where 
it  is  pufhed  backward  ;  but  in  the  mod  frequent  kind 
of  luxation  of  this  joint,  where  the  head  of  the  bone 
is  lodged  in  the  armpit,  the  arm  fhould  uniformly  be 
drawn  fomewhat  obliquely  downward  :  if  extended 
when  raifed  to  a  right  angle  with  the  body,  it  would 
be  drawn  againft  the  neck  of  the  fcapula,  by  which 
much  pain  would  be  excited,  and  the  reduction  fruf- 
trated.  Of  this  I  have  feen  many  inftances,  as  every 
practitioner  muft:  have  done. 

It  fhould  be  a  general  rule  in  the  treatment  of  eve- 
ry luxation,  to  vary  the  direction  in  which  the  exten- 
fion  is  made  as  foon  as  any  confiderable  refiftance  is 
met  with  ;  but  in  luxations  of  the  humerus,  attention 
to  the  obfervations  I  have  juft  throv/n  out  will  for  the 
moft  part  prove  fufficient. 

In  reducing  luxations  of  this  joint,  it  has  been  the 
prevailing  practice  to  prefs  the  fcapula  forvvard  and 
downward  :  nearly  the  reverfe  of  this,  however,  fhould 
be  adopted.  By  prefling  the  fcapula  downward,  we 
force  it  againft  the  head  of  the  humerus,  the  very 
thing  we  ought  moft  carefully  to  avoid  :  and  by  forc- 
ing it  forward,  it  is  evident  that  the  end  of  the  hume- 
rus will  not  be  fo  eafily  drawn  out  from  beneath  it,  as 
when  the  afliftant  is  defired  to  pull  it  backward  in  the 
manner  I  have  mentioned. 

II.  The  mode  of  treatment  I  have  juft  been  de- 
fcribing,  will  fucceed  in  almoft  every  inftance  of  recent 


Sea.  IX.  Joint  of  the  Shoulder.  421 

luxation  ;  and  it  will  feldom  fail  even  in  cafes  of  long 
{landing,  where  the  redudion  of  the  diflocated  bone 
is  prafticable :  but  when  a  greater  force  is  required 
than  can  be  applied  in  this  manner,  the  inftrument 
reprefented  in  Plate  LXXXIX.  may  be  employed.  It 
was  invented  by  the  late  Mr.  Freke,  of  London  ;  and 
it  anfwers  the  purpofe  of  extenfion  better,  and  with 
more  exadnels,  than  any  that  I  have  feen.  It  is  de- 
lineated exadly  from  the  plate  given  of  it  by  Mr, 
Freke  ;  but  it  admits  of  fome  improvements.  The 
ftrap  A  A  which  paiTes  over  the  flioulder,  prefles 
down  the  fcapula,  and  thus  impedes  the  rctludion  of 
the  bone  :  it  fliould  therefore  be  either  entirely  wanting, 
or  made  with  a  flit  to  pafs  over  the  arm  fo  as  to  draw  the 
fcapula  back  :  in  which  cafe,  inftead  of  pafling  oblique- 
ly downwards  to  be  fixed  in  the  floor,  it  fliould  pafs 
flraight  acrofs,  and  be  fixed  in  a  poft  on  a  line  with 
the  flioulder. 

I  have  already  obferved,  that  the  ufe  of  a  lever  in 
raifmg  a  luxated  humerus  is  both  unneceflTary  and  dan- 
gerous :  the  lever  of  this  inftrument,  therefore,  infliead 
of  being  moveable,  fliould  be  fixed  fo  as  only  to  ferve 
as  a  fupport  to  the  arm  ;  or  if  it  ever  is  ufed  as  a  lev- 
er, it  fliould  be  managed  with  the  utmofl  caution. 
The  principal  advantage  that  we  derive  from  this  in- 
ftrument, is  our  being  able,  by  means  of  it,  to  apply 
any  force  that  may  be  necefl'ary  in  the  nioft  gradual 
manner ;  an  objed  of  the  firfl:  importance  in  the  re- 
duction of  luxations :  it  alfo  extends  the  arm  in  any 
diredion  we  may  judge  proper ;  by  which  it  can  at 
once  be  adapted  to  any  variety  of  luxation. 

Swelling,  pain,  and  inflammation,  when  they  occur 
as  confequences  of  luxations  of  the  arm,  are  to  be  re- 
moved by  the  remedies  ufually  employed  in  fuch  ca- 
fes, but  chiefly  by  local  bloodletting  with  leeches. 

The  round  head  of  the  biceps  flexor  cubiti,  which 
pafles  through  the  joint  of  the  Ihoulder,  and  is  lodged 
in  a  groove  in  the  head  of  the  humerus,  is  apt  to  be 
feparated  from  this  bone  when  it  is  forced  far  out  of 


422  Of  Luxations  of  the  Chap.  XL. 

its  natural  fituatlon,  and  thus  induces  a  flift'  unwieldy 
ftate  of  the  arm :  for  the  moft  part  it  returns  imme- 
diately to  this  groove  on  the  diflocation  being  reduc- 
ed ;  fo  that  there  is  commonly  caufe  to  fufpect  that  it 
conthiues  to  be  difplaced  when  any  unufual  pain,  (lift- 
nefs  or  tenfion  remain.  The  moft  certain  method  of 
replacing  it  is  to  move  the  arm  from  time  to  time  in 
every  variety  of  way ;  and  we  know  that  it  is  replac- 
ed, by  an  inftantaneous  removal  of  the  diftrefs. 

The  glenoid  cavity  of  the  fcapula  being  very  fuper- 
ficial,  the  head  of  the  humerus  is  apt  to  fall  out  again, 
even  after  it  has  been  completely  replaced ;  particu- 
larly when  it  has  been  frequently  luxated.  The  moft 
certain  method  of  preventing  this  is  to  fupport  the 
arm  in  a  fling,  as  is  reprefented  in  Plate  XC-VI.  fig.  2, 
till  the  parts  recover  their  tone.  Blifters  applied  to 
the  flioulder,  and  pumping  cold  water  over  the  joint, 
have  alfo  proved  ufeful  for  this  purpofe. 


SECTION    X. 


Of  Luxations  of  the  Fore-arm  at  the  foint  of  the 
Elbow* 

THE  bones  of  the  fore-atm  at  the  elbow  are  more 
frequently  diilocated  upward  and  backward  than 
in  any  other  direction :  they  can  fcarcely  be  luxated 
laterally  or  forward,  if  the  injury  be  not  at  the  fame 
time  accompanied  with  a  fradure  of  the  olecranon  or 
top  of  the  ulna,  as  will  be  readily  perceived  on  ex- 
amining the  connection  of  that  procefs  with  the  cavi- 
ty in  the  pofterior  part  of  the  os  humeri. 

As  the  joint  of  the  elbow  is  not  deeply  covered 
with  foft  parts,  luxations  of  the  bones  are  eafily  dif- 
covered  as  long  as  fwelling  and  tenfion  have  not 
taken  place.  When  thefe  iymptoms  occur  to  any 
extent,  it  is  often  difficult  to  diftinguifh  either  the  na- 


Sed.  X.  Fore-arm  at  the  Elbow,  423 

ture  or  extent  of  the  injury  with  which  they  are  con- 
ne£led.  When  the  luxation  is  backward,  the  olecra- 
non is  felt  on  the  back  part  of  the  arm,  and  the  con- 
dyles of  the  humerus  are  pufhed  forward.  When  the 
olecranon  is  broken  off,  and  the  ulna  and  radius  pulh- 
ed  forward,  they  are  alfo  apt  to  be  drawn  upward  on 
the  anterior  part  of  the  humerus,  when  the  condyles 
of  that  bone  are  difcovered  behind.  The  extent  of 
the  joint  is  fo  confiderable  from  one  fide  to  the  other, 
that  the  bones  compofing  it  can  never  be  completely 
luxated  laterally,  unlefs  the  foft  parts  with  which  they 
are  covered  are  much  lacerated.  In  whatever  way 
they  are  difplaced,  the  joint  becomes  immediately  ftiff 
and  immoveable. 

In  the  reduction  of  thefe  diflocatlons,  the  patient 
ihould  be  feated  on  a  chair  of  a  convenient  height, 
and  the  arm  firmly  fecured  by  an  affiftant  :  when  the 
bones  are  luxated  backward,  the  fore-arm  fliould  be 
moderately  bent,  in  order  to  relax  the  flexor  mufcles : 
while  in  this  pofition  it  fliould  be  flowly  and  gradual- 
ly extended  ;  and  if  care  be  taken  to  increafe  the  cur- 
vature of  the  elbow  in  proportion  as  the  extenfion  is 
made,  we  fcldom  or  never  fail  to  complete  the  reduc- 
tion. Where  the  olecranon  is  broken  off",  and  the 
ends  of  the  radius  and  ulna  puflied  forward  and  drawn 
up  upon  the  humerus,  we  are  under  the  neceflity  of 
extending  the  arm  while  in  a  fl:raight  pofition,  as  in 
this  cafe  the  heads  of  thefe  bones  are  puflied  back  up- 
on the  anterior  part  of  the  humerus  on  the  leafl:  at- 
tempt to  bend  them.  The  extenfion  fliould  be  con- 
tinued till  the  ends  of  both  bones  are  pulled  fomewhat 
lower  than  the  mofl:  depending  point  of  the  humerus, 
when  they  will  either  regain  their  fituation  by  the  ac- 
tion of  the  mufcles,  or  be  eafily  forced  into  it. 

In  lateral  diflocations  of  thefe  bones,  the  extenfion 
muft:  alfo  be  continued  till  they  have  clearly  pafl'ed  the 
end  of  the  humerus,  when  by  moderate  lateral  pref- 
fure  they  will  for  the  mofl;  part  be  eafily  replaced. 
Of  whatever  kind  the  diflocation  may  be,  the  extenfion 


424  Of  Luxations  cj the  Chap.  XL. 

fliould  be  made  by  afliftants  grafping  the  arm  imme- 
diately above  the  wrifl ;  and  while  they  are  thus  em- 
ployed, much  advantage  may  be  gained  by  the  fur- 
geon  preffing  down  the  heads  of  the  bones. 

In  two  cafes  of  diflocation  of  thefe  bones,  where 
their  heads  were  drawn  up  upon  the  back  of  the  hu- 
merus, the  reduction  was  not  accomphfhed,  although 
a  great  force  was  applied,  not  only  in  pulling  at  the 
under  part  of  the  arm,  but  in  pufiiing  down  the  heads 
of  the  difplaced  bones.  In  one  of  them,  where  the 
olecranon  was  pufhed  through  the  teguments,  that  part 
of  the  bone  was  fawn  off,  by  which  the  reduftion  was 
effected  :  in  the  other,  this  expedient  was  not  advifed  ; 
and  the  practitioner  finding  all  his  efforts  to  reduce 
the  bones  prove  abortive,  the  limb  vv^as  amputated. 
As  the  extenfion  in  both  was  applied  w^hile  the  arm 
was  flretched  out,  and  as  I  have  never  failed  in  fimi- 
lar  cafes  where  the  arm  was  bent,  I  conclude,  that  in 
the  one  the  arm  would  have  been  faved,  and  in  the 
other  the  joint  preferved  entire,  if  this  practice  had 
been  adopted. 

The  reduction  being  completed,  the  fore-arm  fiiould 
be  kept  in  a  relaxed  pofition,  by  keeping  the  elbow 
moderately  bent. 

Thefe  bones,  w^hen  reduced,  do  not  readily  fall  again 
out  of  their  place  ;  but  it  is  proper  in  this,  as  in  every 
cafe  of  luxation,  to  preferve  the  limb  as  much  at  reft 
as  poffible  till  the  injured  parts  have  recovered  their 
tone. 

The  bones  of  the  fore-arm  are  alfo  liable  to  be  dif- 
located  in  their  connection  with  each  other.  At  the 
joint  of  the  elbow  a  projecting  part  of  the  radius  is 
lodged,  and  moves  in  a  correfponding  cavity  of  the 
ulna  ;  and  below,  a  portion  of  the  ulna  is  received  by 
a  fimilar  cavity  in  the  radius.  Inftances  have  occur- 
red of  thefe  bones  being  feparated  from  each  other  at 
both  thefe  points  of  connection  ;  but  any  feparation 
of  this  kind  is  more  apt  to  happen  at  the  wrift  than  at 
the  elbow.     It  is  known  to  have  occurred,  by  all  the 


Se6t.  XI.  Bones  of  the  Wriji.  425 

ufual  figns  of  luxations  :  by  pain,  fwelling,  and  diftor- 
tion  in  the  injured  part ;  by  the  motion  of  the  joint 
being  impaired  ;  and  by  manual  examination. 

In  general,  the  difplaced  bone  is  eafily  put  into  its 
fituation ;  but  for  the  moll  part  we  find  it  difficult  to 
retain  it.  The  mofl  certain  method  of  efl'ecling  this, 
is,  to  put  a  long  firm  fplint  along  the  outfide  of  the 
arm  from  the  elbow  down  to  the  points  of  the  fingers, 
and  another  of  the  fame  length  on  the  infide ;  the 
whole  to  be  Iccured  with  a  flannel  roller,  and  the  arm 
hung  in  the  fling  reprefented  in  Plate  XCVI.  fig.  2. 
By  this  we  prevent  the  rotatory  motion  of  the  radius, 
and  the  pronation  and  fupination  of  the  hand  ;  and  if 
this  is  guarded  againlt  for  a  fufficient  length  of  time, 
a  cure  may  at  lafi  be  expe£led,  while  want  of  atten- 
tion to  this  is  frequently  the  caufe  of  the  joint  at  the 
wrill  remaining  fliifl:'  for  life ;  of  which  I  have  met 
with  various  inllances. 


SECTION     XI. 

Of  Luxaiions  of  the  Bones  of  the  WriJi, 

THE  bones  of  the  wrift  are  not  fo  frequently  lux- 
ated as  might  be  expedled  from  the  fmallnefs  of 
their  fize,  owing  to  their  being  firmly  connected  by 
ligaments ;  as  well  as  to  the  flrength  which  they  de- 
rive from  the  whole  tending  to  form  a  kind  of  arch  ; 
the  convex  part  of  which  being  on  the  outer  or  back 
part  of  the  hand,  where  it  is  mofl:  expofed  to  injuries, 
is  particularly  well  calculated  for  preventing  any  of  the 
bones  from  being  difplaced. 

Degrees  of  force,  however,  are  fometimes  applied 
to  them  which  they  are  unable  to  refill.  From  their 
form,  it  will  appear,  that  they  will  mofl;  readily  be  dif- 
located  outward.  The  three  fuperior  carpal  bones, 
which  form  a  kind  of  projeding  head,  that  is  lodged 


426  Of  Luxations  of  the  Chap.  XL. 

in  a  fuperficlal  cavity  in  the  under  extremities  of  the 
ulna  and  radius,  may  cither  be  diflocated  at  this  joint, 
or  they  may  be  feparated  from  the  five  inferior  bones 
of  the  wrift.  In  fome  inftances,  one  or  more  of  thefe 
bones  are  feparated  from  each  other ;  and  in  others 
they  are  diflocated  at  their  connexion  with  the  bones 
of  the  metacarpus  and  the  fuperior  bone  of  the  thumb. 

As  thefe  bones  are  not  thickly  covered  with  foft 
parts,  the  nature  of  the  injury  becomes  immediately 
obvious  :  but  in  fome  cafes,  where  perhaps  a  fmgle 
bone  is  only  partially  difplaced,  if  the  parts  be  not  ex- 
amined with  attention,  the  fymptoms  that  occur  are 
apt  to  be  attributed  to  a  fprain  ;  and  the  real  caufe  of 
them  being  overlooked,  a  permanent  lamenefs  is  thus 
induced,  which  with  much  eafe  might  have  been  pre- 
vented. Of  this  I  have  met  with  various  inftances. 
Similar  occurrences,  however,  may  always  be  prevent- 
ed by  an  early  and  attentive  examination  of  the  injur- 
ed parts. 

In  reducing  luxations  of  thefe  bones,  we  are  in  gen- 
eral defired  to  ftretch  the  arm  and  hand  upon  a  table, 
and  while  they  are  in  this  pofition,  to  pufli  them  into 
their  fituations :  but  it  is  better  to  have  the  arm  and 
hand  fupported  by  two  alTiftants,  as  in  this  fituation 
the  furgeon  gets  ready  accefs  to  both  fides  of  the  wrift. 
The  affiftants  fliould  be  deftred  to  keep  the  parts  fuf- 
ficiently  firm,  but  not  to  ftretch  them  ;  and  when  in 
this  fituation,  the  furgeon  will  feldom  find  it  difficult 
to  pufli  the  bones  into  their  places.  They  muft  be 
retained  by  fplints  and  bandages  in  the  manner  men- 
tioned in  the  laft  feftion  ;  and  as  diflocations  of  thefe 
bones  are  very  apt  to  induce  inflammation  of  the  lig- 
aments and  other  contiguous  foft  parts,  repeated  ap- 
plications of  leeches  ihould  be  advifed  as  the  moft  cer- 
tain preventive. 


Se£t.  XIL         Metacarpus  and  Fingers.  427 


SECTION    XII. 

Of  Luxations  of  the  Bones  of  the  Metacarpus  and 
Fingers. 

WE  have  feen  in  the  lafl  fedion  that  the  meta- 
carpal bones  may  be  diflocatcd  at  their  junc- 
tion with  the  bones  of  the  wrifl ;  and  they  are  fome- 
times  difplaced  at  their  under  extiemities,  where  they 
are  connefted  with  the  bones  of  the  fingers.  They 
are  not  fo  frequently  luxated,  however,  as  at  hrfl:  view 
might  be  expected  ;  probably  from  the  joint  of  the 
wrift  being  fo  moveable,  that  the  whole  hand  readily 
yields  to  any  force  that  is  applied  to  it. 

The  bones  of  the  fingers  and  thumb  are  alfo  fome- 
tlmes  luxated  ;  but  we  likewife  confider  the  mobility 
of  thefe  bones  as  the  principal  reafon  of  their  being 
lefs  frequently  diflocated  than  many  of  the  largefl:  and 
flrongcfl  bones  that  are  more  firmly  connected  to- 
gether. 

Diflocations  of  thefe  bones  are  eafily  difcovered  by 
all  the  ufual  fymptoms  of  luxations  ;  but  particularly 
by  the  deformity  v.'hich  they  produce,  which  in  this 
fituation  is  always  confpicuous. 

When  any  of  the  metacarpal  bones  are  difplaced  at 
their  connection  with  the  bones  of  the  wrift,  the  bed 
method  of  reducing  them  is,  by  keeping  the  arm  ftea- 
dily  fixed,  and  pulhing  them  from  above  downward, 
while  the  hand  remains  loofe  and  moveable.  When 
the  firft  phalanx  of  any  of  the  fingers  is  moved  from 
its  junction  with  the  correfponding  metacarpal  bone, 
it  is  to  be  replaced  by  one  affiftant  fi.xing  the  hard, 
while  another  draws  down  the  diflocated  finger,  which 
fliould  be  done  by  grafping  the  firft  phalanx  only,  in 
order  to  prevent  the  other  joints  of  the  finger  from  be- 
ing hurt.     Diflocations  of  all  the  other  joints  of  the 


428  Of  Luxations  of  the  Chap.  XL. 

fingers,  as  well  as  of  the  thumbs,  are  to  be  managed 
in  the  fame  manner. 

In  the  reduclion  of  thefe  diflocations,  the  bone  fhould 
not  be  pulled  down  till  it  is  fomewhat  raifed  or  eleva- 
ted from  the  contiguous  bone  ;  for  as  all  the  bones  of 
the  fingers  and  thumbs,  as  well  as  thofe  of  the  meta- 
carpus, are  thicker  at  their  extremities  than  in  any 
other  part,  thefe  projections  are  apt  to  be  forced  againfl 
each  other  when  the  extenfion  is  made  in  a  ftraight 
direclion.  In  this  manner  the  greateft  force  has  fre- 
quently been  employed  in  vain  ;  nay,  fingers  have  been 
amputated  where  this  alone  prevented  luxations  from 
being  reduced,  and  in  which  a  very  inconfiderable  force 
would  have  proved  fuccefsful,  if  the  difplaced  bone 
had  been  fomewhat  feparated  from  the  other  before 
any  force  was  applied  for  extending  it. 


SECTION     XIII. 

Of  Luxations  of  the  Femur  at  the  Hip  foint, 

THE  focket  or  acetabulum,  formed  by  the  ofla  in- 
nominata,  for  lodging  the  head  of  the  thigh 
bone,  is  fo  deep  ;  the  brim  of  the  focket  in  a  recent 
fubjedt  contracts  fo  much  about  the  neck  of  this  bone  ; 
the  head  of  the  bone  is  fo  firmly  tied  down  to  the  bot- 
tom of  the  focket  by  a  ftrong  ligament ;  and  it  is  fo 
confined  by  ftrong  mufcles,  that  we  would  not  a  pri- 
ori fuppofe  that  it  could  be  luxated  by  external  vio- 
lence :  we  would  rather  imagine  that  it  would  break 
at  the  neck  where  it  is  weakeft,  than  that  the  head  of 
it  fliould  ever  be  forced  from  its  focket :  this  opinion 
has  accordingly  been  adopted  by  many  in  all  ages. 
For  a  confiderable  time  I  was  difpofed  to  favour  it, 
from  having  obferved  feveral  cafes  which  at  firft  were 
fuppofed  to  be  luxations,  but  which  proved  to  be  frac- 
tures of  the  neck  of  the  femur.     In  the  courfe  of  the 


Sea.  XIII.         Femur  at  the  Hip  Joint.  429 

lad  few  years,  however,  I  have  feen  feveral  cafes  in 
which  I  was  convinced  that  the  thigh  bone  was  luxa- 
ted. The  nature  of  the  fymptoms  gave  reafon  to  im- 
agine that  they  arofe  from  luxations  j  and  they  were 
proved  to  do  fo  by  the  patient's  being  inftantancoufly 
and  completely  relieved,  and  rendered  quite  able  to 
walk,  on  the  head  of  the  bone  being  replaced  j  which 
in  a  frafture  of  the  bone  could  not  happen. 

In  treating  of  fradures  of  the  thigh  bone,  the  cir- 
cumftances  by  which  fraftures  of  the  neck  of  it  may 
mod  readily  be  dillinguiflied  from  luxations,  were 
mentioned  :  1  fhall  therefore  refer  for  this  part  of 
our  fubjed  to  the  eleventh  Seftion  of  the  preceding 
Chapter. 

It  is  faid  by  authors,  that  the  head  of  the  femur 
may  be  luxated  in  various  directions,  namely,  upward 
and  backward,  upward  and  forward,  downward  and 
backward,  downward  and  forward,  and  I  may  adddi- 
redlly  downward.  That  all  of  thefe  may  happen,  I 
cannot  take  it  upon  me  to  deny  ;  but  I  believe  few 
pradiitioners  have  met  with  an  inltance  of  the  firft  and 
third.  The  fecond  variety,  where  the  head  of  the 
bone  paffes  up  upon  the  os  pubis,  may  happen  ;  as 
may  likewife  the  laft,  where  it  is  forced  directly  down  ; 
but  I  have  never  feen  any  variety  of  this  luxation  if  it 
be  not  that  in  which  the  head  of  the  femur  is  pufhed 
downward  and  forward,  and  lodged  in  the  foramen 
ovale.  All  praftitioners  admit,  that  the  bone  is  mod 
frequently  dillocated  in  this  diredion  ;  and  an  exam- 
ination of  the  il-celeton,  as  well  as  of  the  recent  fubjeft, 
will  {how  why  it  fliould  be  fo.  The  brim  of  the  fock- 
ct  over  all  the  upper  and  back  part  of  it,  is  not  only 
ftronger,  but  more  elevated  than  the  red  of  it.  It 
falls  away  as  it  defcends  ;  and  on  the  anterior  under 
p:\rt  of  it  there  is  a  confiderable  vacancy  in  the  bone, 
the  fpace  being  filled  with  a  ligament  only  ;  and  as 
tiiis  opening  is  fuiTicicntly  large  to  admit  the  head  of 
the  femur,  we  eafily  fee  how  luxations  lliould  be  mod 
apt  to  occur  here. 


43^  0/"  Luxations  of  the  Chap.  XL. 

Every  luxation  of  the  femur  mufl  be  productive  of 
lamenefs,  and  of  pain,  tenfion,  and  other  fymptoms 
with  which  other  luxations  are  accompanied.  When 
the  head  of  the  bone  palTes  upward  and  backward,  the 
leg  muft  be  much  fliorter  than  the  other  ;  infomuch 
that  the  points  of  the  toes  only  will  touch  the  ground 
when  the  patient  is  {landing  upon  the  other  foot ;  the 
great  trochanter  of  the  thigh  bone  will  be  higher  than 
in  the  other  fide  ;  the  knee  and  foot  turned  inward  ; 
and  a  good  deal  of  pain  nmll  be  induced  by  every  at- 
tempt to  turn  them  out. 

When  the  femur  is  luxated  upward  and  forward, 
the  leg  muft  be  fhortened  ;  the  head  of  the  bone  will 
be  felt  refling  above  the  os  pubis  in  the  groin  ;  the 
great  trochanter  will  be  on  the  upper  and  anterior  part 
of  the  thigh  near  the  groin,  while  a  vacancy  is  difcov- 
ered  in  that  part  of  the  hip  which  it  ought  to  occupy  ; 
the  knee  and  toes  will  be  turned  outwards  ;  and  if  the 
diflocation  be  not  foon  reduced,  pain,  tenfion,  and  in- 
flammation, will  occur  in  the  fpermatic  cord  and  tef- 
tis,  from  the  prelTure  made  upon  the  cord  by  the  head 
of  the  bone. 

If  ever  this  bone  is  luxated  downward  and  back- 
ward, the  leg  will  be  confiderably  longer  than  the  oth- 
er ;  the  knee  and  toes  will  be  turned  inward  ;  and  the 
great  trochanter  will  be  much  lower  than  the  fame 
protuberance  of  the  other  limb.  When  the  head  of 
the  bones  pail'es  directly  downward,  the  leg  will  alfo 
be  longer  than  the  other,  and  the  trochanter  will  like- 
wife  be  lower  ;  but  the  knee  and  toes  will  retain  near- 
ly their  natural  iituation  ;  only  every  attempt  to  move 
them  will  be  productive  of  pain. 

In  the  moll  frequent  luxation  of  the  femur,  the  \Qg 
appears  to  be  confiderably  longer  than  the  other  ;  the 
knee  and  points  of  the  toes  are  turned  outward,  nor 
can  they  be  moved  either  farther  outward  or  inward 
but  with  much  pain  :  all  the  muicles  in  the  internal 
part  of  the  thigh  are  tenfe  and  painful ;  the  femur  can- 
not be  felt  on  the  outfide  farther  up  than  the  middle 


Sea.  XIII.         Femur  at  the  Hip  Joint.  431 

of  the  thigh  ;  a  vacancy  is  difcovered  in  the  ufual  feat 
of  the  great  trochanter,  which  is  found  farther  dowa 
and  on  the  anterior  part  of  the  thigh,  while  the  head 
of  the  femur  is  plainly  felt  a  litde  below  the  groin  ; 
being  feated,  as  I  have  obfervcd  above,  in  the  foramen 
ovale. 

In  luxations  of  the  femur,  the  difficulty  and  uncer- 
tainty of  reducing  them  has  been  confidered  as  fo  great, 
that  in  general  we  have  been  advifed  to  give  a  very 
doubtful  prognofis  of  the  event.  In  cafes  of  long  du- 
ration, this  iliould  always  be  done :  for  befides  other 
caufes  which  add  to  the  difficulty  of  rcdudion,  the 
muicles  here  are  fo  ftrong  that  they  refill,  in  the  mod 
powerful  manner,  every  attempt  to  diflodge  the  head 
of  the  bone  after  it  has  been  long  fixed  among  them  : 
by  contrading  round  the  neck  of  the  bone,  they  muft 
even  be  torn  afunder  before  it  can  be  reduced  :  but  in 
recent  luxations  we  have  not  this  difficulty  to  encoun- 
ter ;  and  we  know  that  with  proper  management  the 
bone  may  in  almofl  every  inftance  be  reduced. 

The  redu6lion  of  this  bone  is  commonly  attempted 
by  pulling  the  limb  downward  j  and  it  feems  to  be  an 
opinion  very  univerfally  received,  that  any  force  we 
employ  ffiould  be  applied  in  this  direction.  Some  ad- 
vife  the  limb  to  be  drawn  directly  down  from  the  part 
in  which  the  head  of  the  bone  is  lodged ;  others  de- 
fire  it  to  be  pulled  exaiStly  in  a  line  with  the  hip  joint, 
while  others  turn  the  knee  fomewhat  inward.  The 
patient  being  placed  upon  his  back,  and  properly  fc- 
cured,  the  limb  is  extended  in  one  or  other  of  thcfe 
diredions,  either  till  the  reduclion  is  accomplilhed,  or 
till  fuch  a  force  is  applied  as  makes  the  operator  afraid 
of  doing  harm  were  he  to  proceed  farther. 

It  muft  be  allowed,  that  diflocations  of  the  femur 
have  in  various  inftances  been  reduced  in  this  manner  : 
it  might  often  fucceed  where  the  head  of  the  bone  is 
forced  upwards  ;  but  I  may  without  hefitation  affiert, 
that  even  in  this  cafe  the  redudion  might  be  effe£ted 
with  lefs  force  in  a  different  manner  j  and  in  a  great 


432  Of  Luxatlom  cf  the  Chap.  XL, 

proportion  of  cafes,  where  the  head  of  the  bone  is 
lodged  in  the  foramen  ovale,  or  where  it  is  forced  di- 
rectly downwards,  that  we  muft  neceflarily  fail  entire- 
ly by  confining  the  line  of  extenfion  to  any  of  the  di- 
rections I  have  mentioned. 

In  whatever  way  the  head  of  the  femur  is  luxated, 
it  muft  pafs  over  fome  inequalities  or  prominent  parts 
of  the  contiguous  bones  :  thefe  it  muft  again  pafs  over 
before  it  is  reduced ;  at  leaft  this  muft  be  the  cafe  if 
we  wifh  it  to  return  by  the  fame  route,  arid  it  will  be 
admitted  in  the  treatment  of  luxations  to  be  a  good 
general  rule,  to  endeavour  to  replace  the  bone  by  the 
opening  at  which  it  pafled  out.  But  where  the  limb 
is  only  pulled  downward  in  the  ufual  way,  the  head 
of  the  bone  will  be  forced  againft  the  projedting  brim 
of  the  focket,  if  the  diflocation  is  upward  ;  or  it  will 
be  drawn  to  a  ftill  greater  diftance  from  the  joint 
where  the  bone  is  diflocated  either  dire£tly  downward, 
or  lodged  in  the  foramen  ovale  in  the  upper  and  inner 
part  of  the  thigh.  Wherever  the  head  of  the  bone 
may  be  lodged,  it  ftiould  be  completely  raifed  above 
any  projecting  part  of  the  contiguous  bones  before 
any  other  attempt  is  made  for  reducing  it.  As  this 
will  remove  the  principal  impediment  to  the  reduction, 
if  the  mufcles  of  the  limb  are  at  the  fame  time  relax- 
ed, it  will  eafily  be  drawn  into  the  focket  when  the 
diflocation  is  upward,  or  puflied  into  it  where  the  head 
of  the  bone  is  already  beneath  it. 

In  the  moft  frequent  variety  of  this  luxation,  where 
the  head  of  the  bone  is  puflied  downward  and  for- 
ward, I  have  fucceedcd  in  the  fol-ov^'ing  manner :  the 
patient  is  laid  upon  his  back  acrofs  a  bed,  and  firmly 
fecured  by  tv/o  or  three  affiftants :  a  broad  ftrap,  or 
table  cloth,  properly  folded,  is  pafTed  between  his 
thighs,  and  over  the  g;roin  on  the  found  fide,  and  giv- 
en to  two  other  aififtants  :  a  fimilar  ftrap  is  paifed 
round  the  luxated  thigh  as  near  as  polfible  to  the  head 
of  it ;  the  ends  of  which  muft  be  given  to  an  afiiftant 
ftanding  on  the  oppofite  fide :  the  belt  reprefented  in 


Se£^.  Xin.         Femur  at  the  Hip  yolnti  433 

Plate  LXXXVITI.  fig.  3.  being  previoufly  fixed  upon 
the  under  part  of  the  thigh,  the  flraps  conne£ted  with 
it  are  given  to  an  alliftant  or  two,  while  the  knee  is 
fupported  by  another  affiftant  with  the  leg  moderately 
bent.  The  thigh  is  now  to  be  moderately  (Iretched 
by  the  aiTiftants  who  have  the  charge  of  the  flraps  at 
the  under  part  of  it ;  but  the  extenfion  fliould  not  be 
carried  farther  than  what  may  be  confidered  as  necef- 
fary  for  drawing  the  head  of  the  bone  down  to  the 
under  part  of  the  foramen  ovale  ;  and  this  may  be  al- 
ways done  with  a  moderate  force.  The  ftrap  round 
the  top  of  the  thigh  muft  now  be  firmly  pulled  by 
thofe  who  have  the  charge  of  it ;  who,  (landing  fome- 
what  higher  than  the  patient,  fliould  draw  the  thigh 
upward  and  inward  *,  and  the  extenfion  fhould  be  con- 
tinued in  this  direftion  till  there  is  reafon  to  fuppofe 
that  the  head  of  the  bone  is  clearly  raifed  from  the 
foramen  in  which  it  was  lodged.  At  this  time  the 
perfon  who  has  the  charge  of  the  knee  fhould  be  defired 
to  move  it  fomewhat  inward,  and  to  pufli  the  head  of 
the  bone  upward  and  obliquely  outwgj'd  :  he  will  do 
this  with  the  greatefl  certainty  of  fuccefs,  if  he  fecures 
the  knee  with  one  hand,  and  the  foot  with  the  other, 
at  the  fame  time  that  he  takes  care  to  keep  the  leg  jufl 
fo  much  bent  as  may  relax  all  the  flexor  mufcles  with- 
out flretching  the  extenfors.  If  the  different  afTiflants 
perform  their  parts  properly,  the  firfl  attempt  will  an- 
fwcr  ;  but  if  any  of  them  have  failed,  particularly  if  the 
head  of  the  bone  has  not  been  fulTiciently  raifed  from 
the  hollow  in  the  foramen  ovale  before  being  pufhed 
upwards,  the  attempt  muft  be  repeated. 

As  the  head  of  the  bone  may  for  the  mofl  part  be 
felt  outwardly,  the  furgeon  may  in  general  afccrtain 
■with  certainty  whether  it  is  fufficiently  raifed  or  not. 
If  he  finds  it  rife  eafily,  the  force  may  be  continued 
till  it  appears  to  be  about  an  inch  higher  than  when  it 
was  fird  applied  ;  while,  on  the  contrary,  if  it  yields 
with  difliculty,  there  will  be  reafon  to  fufped  that 

Vol.  III.  E  e 


434  Q/"  Lunations  Chap.  XL. 

fome  part  of  the  head  of  the  bone  is  fixed  or  locked 
in  the  upper  part  of  the  foramen  ovale  ;  m  which  cafe 
the  force  in  this  diredion  fhould  be  difcontinued,  and 
the  other  affiftants  at  the  knee  being  direded  to  in- 
creafe  the  extenfion  downward,  it  will  afterwards  be 
more  eafily  raifed. 

In  whatever  diredion  the  bone  may  be  diflocated, 
the  point  requiring  moft  of  our  attention,  is  the  raif- 
ing  the  head  of  the  bone  fufficiently  before  any  attempt 
is  made  to  force  it  into  the  focket.  This  being  ac- 
compliflied,  a  very  flight  force  will  in  general  draw 
it  down  when  the  diflocation  is  upward ;  and  when 
diflocated  downward,  whether  it  is  fomewhat  back- 
ward or  diredly  on  a  line  with  the  focket,  it  will  be 
eafily  puflied  up. 

In  this  manner  recent  luxations  of  this  joint  may  for 
the  mofl:  part  be  reduced  ;  and  the  fame  treatment  is 
perhaps  the  befl:  even  in  luxations  of  long  duration. 
In  thefe  it  will  fometimes  fail ;  but  it  will  fucceed,  I 
believe,  as  frequently  as  any  other  that  has  yet  been 
propofed,  whil^q  it  is  not  productive  of  the  dreadful 
pain  that  commonly  enfues  from  the  ufe  of  thofe  ma- 
chines that  have  been  invented  for  a  greater  extenfion 
of  the  limb.  When  any  additional  force,  however, 
is  judged  neceflary,  it  may  either  be  obtained  by  a 
proper  application  of  Mr.Freke's  machine,  reprefented 
in  Plate  LXXXIX.  of  Mr.  Petit's  in  Plate  LXXXVII. 
fig.  2.  or  of  the  pullies  and  ropes  reprefented  in  Plate 
LXXXVIII.  fig.  2. 

It  (hould  be  remarked,  however,  that  this  kind  of 
aflifl:ance  can  never  be  applicable  where  the  luxation 
is  downward.  Extenfion  of  the  limb  having  been 
confidered  as  neceflary  in  every  variety  of  luxation,  it 
has  often  been  indifcriminately  employed,  whether  the 
head  of  the  bone  was  placed  above  or  below  the  fock- 
et :  it  is  obvious,  however,  that  it  is  in  the  former 
only  that  it  can  ever  prove  ufeful ;  and  in  the  latter, 
that  much  miichief  may  enfue  from  it. 


Sea.  XIV.  of  the  Pafella,  J^^$ 

The  violent  diftenfion  of  the.  mufcles,  and  exten- 
five  laceration  of  the  articular  ligaments,  with  which 
luxations  of  this  bone  muft  always  be  accompanied, 
render  much  care  and  attention  neceffary  long  after 
the  reduction  is  accomplifhed.  Local  bloodletting 
with  leeches,  or  cupping  and  fcarifying,  proves  parti- 
cularly ufeful  here,  and  fliould  be  repeated  more  or 
lefs  frequently  according  to  the  violence  of  the  fymp- 
toms,  and  age  and  habit  of  the  patient ;  and  till  the 
parts  may  be  fuppofed  to  have  recovered  their  tone, 
the  patient  (hould  be  kept  as  much  at  reft  as  pofiible. 

By  many  it  is  imagined  that  the  femur  may  be  par- 
tially luxated  ;  and  the  appearances  which  are  fup- 
pofed to  arife  from  what  is  termed  a  fubluxation  of 
this  bone  are  dcfcribed  by  authors  :  of  thei'e,  howev- 
er, I  have  taken  no  notice,  as  it  is  not  my  opinion 
that  this  bone  can  ever  be  partially  luxated.  The 
head  of  it  is  fo  round,  and  the  brim  of  the  focket  fo 
narrow,  that  whoever  examines  them  will  be  convin- 
ced that  it  cannot  happen.  The  head  of  the  bone 
may,  in  a  gradual  manner,  be  pufiied  out  of  the  ace- 
tabulum by  a  tumor  at  the  bottom,  but  I  do  not  fup- 
pofe  that  it  can  ever  occur  from  external  violence. 


SECTION    XIV. 
Of  Luxatiofis  of  the  Patella, 

THE  patella  may  be  either  partially  or  completely 
luxated,  and  it  may  be  difplaced  either  upward 
or  downward,  outward  or  inward  :  it  may  alfo  be 
luxated  by  itfelf,  or  it  may  be  difplaced  along  with 
the  tibia  and  fibula  in  luxations  of  thefe  bones.  It 
cannot,  however,  be  completely  luxated  in  any  direc- 
tion, if  it  be  not  accompanied  with  a  rupture  of  the 
ligament  by  which  it  is  tied  to  the  tibia,  or  of  the  ten- 

E  E  2 


43^  Of  Luxatiom  of  the  Chap.  XL* 

don  of  the  rectus  mufcle  connected  to  the  upper  part 
of  it ;  and  it  will  be  more  readily  diflocated  inwardly 
than  in  any  other  direction,  owing  to  the  internal 
condyle  of  the  femur  being  fomewhat  lefs  prominent 
than  the  other  :  for  as  this  bone  is  placed  in  fome  de- 
gree between  thefe  condyles,  it  will  neceflarily  be  moft 
eafily  forced  out  at  that  fide  where  it  meets  with  the 
kafl:  refiftance. 

Luxations  of  this  bone  are,  for  the  moft  part,  eafi- 
ly difcovered,  as  it  is  thinly  covered  with  foft  parts  : 
but  when  it  has  been  long  difplaced,  it  is  apt  to  in- 
duce fo  much  tumefaction,  not  only  about  the  joints 
but  over  all  the  contiguous  parts,  as  to  be  diftinguifh- 
ed  with  difficulty.  Even  the  moft  partial  luxation  of 
the  patella  always  gives  confiderable  lamenefs  and 
much  pain  on  every  attempt  to  move  the  joint. 

In  the  redu6tion  of  a  luxated  patella,  the  patient 
fhould  be  placed  either  on  a  bed  or  on  a  tabic,  and 
his  leg  fliould  be  ftretched  out  and  kept  in  this  pof- 
fure  by  an  affiftant^  The  furgeon  fhould  now  lay 
hold  of  the  bone,  and  endeavour  to  pufti  it  into  its- 
fituation  ;  but  inftead  of  puftiing  it  diredly  forward,. 
it  ftiould  firft  be  fomewhat  railed,  otherwife  we  are 
apt  to  force  it  againft  the  condyles  of  the  femur  or 
head  of  the  tibia.  The  beft  method  of  effetting  this 
is  to  prefs  down  the  fide  of  the  bone  moft  diftant  from 
the  joint ;  by  which  the  oppofite  fide  of  it  v^  ill  be 
elevated,  when  a  very  moderate  force  will  prefs  it  in- 
to its  place.  When  the  patella  is  drawn  out  of  its 
fituation  by  the  tibia  and  fibula  being  difplaced  along 
with  it,  it  cannot  be  replaced  till  the  redudion  of 
thefe  bones  is  accompliflied. 


Sea.  XV.  Tibia  and  Fibula,  437 


SECTION    XV. 

Of  Luxations  of  the  Tibia  and  Fibula  at  the  foint  of 
the  Knee, 

THE  tibia  is  the  only  bone  of  the  leg  that  is  im- 
mediately concerned  in  the  joint  of  the  knee  ; 
but  as  this  bone  cannot  be  diflocated  without  drawing 
the  fibula  along  with  it,  I  think  it  right  to  mention 
them  together. 

As  more  ftrength  is  required  in  the  knee  than  in 
any  other  joint  of  the  body,  the  bones  of  which  it  is 
chiefly  formed,  the  femur  and  tibia  are  connecl:ed  to- 
gether by  the  ftrongeft  kind  of  articulation,  namely, 
by  ginglimus  or  the  hinge  like  joint  :  the  furfaces  of 
the  two  bones  are  very  extenfive,  and  they  are  firmly 
tied  together  by  ilrong  ligaments  :  there  is  alfo  reafon 
to  fuppofe,  that  the  moveable  cartilages  placed  be- 
tween the  end^  of  thefe  bones  have  fome  influence  in 
lefl"ening  the  fridion  of  the  joint,  and  in  thus  render- 
ing it  more  firm  than  it  otherwife  would  be. 

The  great  ftrength  of  this  joint  is  the  reafon  of  its 
being  lefs  frequently  diflocated  than  any  other  in  the 
body  '.  it  cannot  indeed  be  completely  diflocated  but 
by  the  application  of  fo  much  force  as  will  not  only 
rupture  the  teguments  which  cover  it,  but  the  ftrong 
ligaments  and  tendons  which  tie  the  bones  together. 
As  this  requires  a  very  unufual  degree  of  violence, 
thefe  bones  are  feldom  forced  entirely  paft  each  other ; 
and  the  fame  reafon  even  prevents  them  from  being 
often  partially  luxated.  When  either  a  complete  or 
partial  luxation,  however,  is  produced,  it  may  happen 
nearly  with  equal  eafe  on  either  fide  ;  but  the  bones 
will  be  more  readily  forced  backward  than  forward, 
owing  to  the  flexor  mufcles  and  tendons  of  the  leg 
being  much  fl:ronger  than  the  extenfors. 


433  Of  Luxaficns  of  the  Chap.  XL» 

The  mofl:  partial  luxation  of  this  joint  is  readily  dif- 
tinguifhed,  not  only  by  the  violent  pain  which  it  ex- 
cites, and  the  lamenefs  with  which  it  is  attended,  but 
by  the  deformity  which  it  produces,  and  which  is  al- 
ways obvious  on  comparing  both  knee  joints  together. 
When  the  patella  is  diflocated  at  the  fame  time  with 
the  tibia  and  fibula,  it  will,  for  the  moll  part,  be  re- 
duced along  with  thefe  bones ;  but  when  this  does 
not  happen,  it  may  be  afterwards  replaced  in  the  man- 
ner I  have  mentioned  in  the  laft  feclion. 

Luxations  of  this  joint  are  to  be  reduced  by  fixing 
the  thigh  with  fufficient  firmnefs,  and  extending  the 
leg  till  the  ends  of  the  bones  are  entirely  clear  of  each 
other ;  when  the  tibia  and  fibula  will  be  eafily  repla- 
ced. In  paitial  luxations,  the  degree  of  extenfion  ne- 
ceflary  for  this  will  be  inconfiderable ;  but  where  the 
bones  are  completely  difplaced,  more  force  will  be  re- 
quired. It  is  fcarcely  necefl'ary  to  obferve,  that  the 
mufcles  of  the  leg  fliould  be  as  much  relaxed  as  pof- 
fible  while  the  force  for  extending  it  is  applying. 

Scarcely  any  joint  is  fo  apt  to  fuffer  from  inflam- 
mation as  that  of  the  knee  ;  fo  that  in  all  fuch  inju- 
ries as  this,  where  the  furrounding  foft  parts  ai'e  fo 
liable  to  inflame  and  become  painful,  the  mofl  ftricl 
antiphlogiftic  courfe  becomes  requifite  ;  local  blood- 
letting (hould  be  prefcribed,  and  repeated  according 
to  the  violence  of  the  fymptoms  and  flrength  of  the; 
patient ;  and  the  limb  Ihould  for  a  confiderable  time 
be  kept  at  perfetl  reft. 

The  upper  as  well  as  the  under  end  of  the  fibula 
is  fometimes  forcibly  feparated  from  the  tibia.  As  the 
fymptoms  which  this  excites  are  fimilar  to  thofe  which 
occur  from  fprains  of  the  mufcles,  the  nature  of  the 
injury  is  often  overlooked.  It  may  almoft  always, 
however,  be  diftinguifhed  by  attentive  manual  exami- 
nation. The  only  method  of  obtaining  relief  is  by  re- 
placing the  bone,  which  for  the  mofl  part  is  eafily 
done,  and  retaining  it  with  a  proper  bandage  till  the 
parts  have  recovered  their  tone. 


Sea.  XVI.  Foot  ai  the  Ankk»  439 

SECTION    XVI. 
Of  Luxations  of  the  Foot  at  the  Joint  of  the  Ankle, 

THE  joint  of  the  ankle  Is  formed  by  the  upper  part 
of  the  aflragalus  or  firft  bone  of  the  foot,  being 
received  into  a  cavity  in  the  under  end  of  the  tibia  ; 
which  is  bounded  externally  by  the  end  of  the  fibula 
projeding  a  confiderable  way  paft  the  end  of  the  tibia. 

The  aftragalus  may  be  diflocated  either  backward 
or  forward,  outward  or  inward,  but  it  is  more  fre- 
quently puflied  inward  than  in  any  other  diredlion. 
The  great  ftrength  of  the  tendo  achillis  prevents  it 
from  flipping  eafily  backward,  and  it  has  alfo  fome  ef- 
fe£l  in  preventing  it  from  going  forward.  It  cannot 
be  puflied  outward  without  breaking  the  projeding 
end  of  the  fibula. 

Diflocations  of  this  joint  are  in  general  eafily  difcov- 
ered  by  the  pain  and  lamenefs  which  they  produce,  as 
well  as  by  the  obvious  alteration  which  they  occafion 
in  the  appearance  of  the  foot.  When  the  aflragalus 
is  puflied  forward,  the  foot  appears  to  be  lengthened 
and  the  heel  fliortened  ;  when  puflied  backward,  the 
foot  is  fhortened  and  the  heel  lengthened  ;  and  when 
luxated,  either  outwardly  or  inwardly,  there  is  always 
a  preternatural  vacancy  on  one  fide  of  the  joint,  and 
a  prominency  on  the  other. 

In  the  reduction  of  this  luxation,  the  patient  fhould 
be  placed  either  upon  a  table  or  on  a  bed,  and  the  leg, 
with  the  knee  bent,  fliould  be  firmly  fecured  by  an  af- 
fiflant  or  two.  The  foot  is  now  to  be  put  into  that 
fituation  which  tends  moft  eft'edually  to  relax  all  the 
mufcles  that  belong  to  it ;  and  being  given  to  an  af- 
fiflant,  he  mufl  be  defired  to  extend  it  in  that  direc- 
tion till  the  moft  prominent  point  of  the  aflragalus  has 
clearly  paffed  the  end  of  the  tibia,  when  the  bone  will 
either  flip  into  its  place,  or  may  be  eafily  forced  into  it. 


440  Of  Luxaticns  cfthe  Chap.  XL. 

As  the  upper  part  of  the  aftragalus  is  not  perfeclly 
round,  but  rather  fomewhat  hollow,  this  joint  is  more 
apt  to  be  partially  luxated  than  any  other  formed  by 
a  ball  and  focket,  as  this  in  fome  meafure  is  :  partial 
luxations  of  it,  however,  are  eafily  reduced. 

Befides  the  antiphlogiftic  courle  that  I  have  advifed 
after  all  luxations  of  the  large  joints,  it  is  particularly 
necelTary  in  luxations  of  the  ankle  to  keep  the  limb 
for  a  confiderable  time  at  the  moil  perfect  relt,  efpe- 
cially  where  the  under  extremity  of  the  fibula  is  brok- 
en, by  the  foot  being  forced  outward  ;  for,  as  the  (la- 
bility of  the  joint  depends  in  a  great  meafure  on  this 
bone,  if  it  be  not  either  rightly  replaced  or  retained  in 
its  fituation,  till  the  cure  of  the  frafture  is  eftefted,  it 
may  afterwards  continue  weak  during  life,  or  be  atr 
tended  with  ftiffnefs  and  a  great  degree  of  pain.  The 
weaknefs  that  fucceeds  to  this  kind  of  injury,  if  it  be 
not  removed  by  thefe  mcafures,  will  be  mod  effeclu- 
ally  obviated  by  a  firm  fplint  of  thin  iron  connected 
with  the  fhoe,  and  applied  along  the  outfide  of  the 
leg  ;  or  by  an  inftrument  invented  by  the  late  Mr, 
Gooch,  reprefented  in  Plate  XCIV.  fig.  4. 


SECTION    XVII. 

Of  Luxations  of  the  Os  Calcis  and  other  Bo7ies  of  the  Foot* 

THE  OS  calcis,  which  is  the  largefl  bone  of  the  foot, 
is  fometimes  diflocated  laterally,  where  it  is  con? 
nedled  with  the  aftragalus.  It  is  prevented  from  be- 
ing pufhed  forward  by  the  other  bones  of  the  foot ; 
and  the  tendo  achillis,  which  is  inferted  into  a  large 
rough  procefs  of  this  bone  which  projects  backward 
and  forms  the  heel,  prevents  it  from  being  luxated  in 
this  direction. 

The  aftragalus  and  os  calcis  are  fometimes  luxated 
at  their  junction  with  the  os  naviculare  and  os  cuboi- 


Sea.  XVII,  Os  Cakis,  Eff^r.  441 

des  ;  and  as  this  joint,  if  it  may  be  fo  termed,  is  at  no 
great  diftance  from  the  ankle,  this  variety  of  luxation 
has,  in  feme  inftances,  been  miftaken  for  luxation  of 
the  ankle.  The  foot  may  at  this  part  be  pufhed  either 
outward  or  inward,  or  be  forced  diredly  downward  : 
it  will  rarely  be  luxated  upward,  as  it  can  fcarcely  be 
expofed  to  external  violence  in  fuch  a  direftion  as 
could  have  this  effed. 

Luxations  of  any  of  thefe  bones  are  readily  difcov- 
ered  by  the  pain  and  lamenefs  with  which  they  are  al- 
ways attended  ;  as  well  as  by  the  alteration  which  they 
produce  on  the  fliape  of  the  foot. 

The  OS  calcis,  when  completely  difplaced,  is  more 
difficult  to  reduce  than  alinofl  any  other  bone  of  the 
foot :  it  can  only  be  done  by  fixing  the  leg  and  foot 
in  fuch  a  pofitlon  as  tends  mod  etfedlually  to  relax 
the  different  mufcles  that  belong  to  them  ;  and  while 
they  are  in  this  pofition,  by  endeavouring  to  force  the 
bone  into  its  fituation  ;  and  this  will  be  more  readily 
done,  if  during  the  operation  the  foot  is  extended. 

In  luxations  of  the  afiiragalus  and  os  calcis  with  the 
OS  naviculare  and  os  cuboides,  as  the  anterior  part  of 
the  foot  is  apt  to  be  drawn  towards  the  heel,  it  be- 
comes neceiTary  to  extend  it  to  fuch  a  degree  as  may 
clear  the  bones  on  the  oppofite  fides  of  the  joint  of 
each  other  ;  for  till  this  is  done,  the  reduction  cannot 
take  place,  while  the  bones  will  immediately  flip  into 
their  fituation  as  foon  as  they  are  drawn  pafl  each 
.other. 

The  other  three  bones  of  the  tarfus,  ufually  terme4 
the  cuneiform  bones,  as  well  as  the  metatarfal  bones, 
and  the  bones  of  the  toes,  are  all  liable  to  be  luxated, 
and  they  may  be  difplaced  almoft  in  every  direftion. 
But  it  is  not  neceffary  to  fpeak  of  the  method  of  re* 
ducing  them  ;  for  the  obfervations  that  I  had  occafion 
to  make  on  diflocations  of  the  bones  of  the  hand  are 
equally  applicable  here  :  fo  that  I  fhall  now  refer  to 
what  was  faid  on  that  fubjecl  in  the  twelfth  Sedion  of 
this  Chapter. 


442  Of  Dijioricd  Limbs,         Chap.  XLI. 


CHAPTER  XLI. 

OF  DISTORTED  LIMBS. 

LIMBS  may  be  diilorted  in  various  ways,  and  by 
difierent  caufes  ;  either  from  a  morbid  ftatc  of 
the  bones,  or  from  a  contracted  ftate  of  the  mufcles, 
or  the  bones  and  mufcles  may  both  be  affeded.  In 
fome  cafes,  diftortions  are  owing  to  original  malcon- 
formation  ;  in  others,  they  arife  in  infancy,  and  in 
fome,  at  more  advanced  periods  of  life. 

For  a  confiderable  time  after  birth,  the  bones  are 
foft  and  pliable,  and  are  eafily  affected  by  the  poftures 
of  the  body.  The  bones  of  the  legs  are  apt  to  be 
crooked  by  children  being  made  to  walk  too  early. 
This  alfo  is  the  effect  of  fome  difeafes,  particularly  of 
rickets,  which  foften  the  bones  fo  much  that  they  ea- 
fily yield  to  the  pofture  of  the  body,  as  well  as  to  the 
ordinary  aQion  of  the  mufcles.  But  the  mofl  fre- 
quent caufe  of  diftorted  limbs  is  that  contraction  of 
the  flexor  mufcles  of  the  leg  and  fore-arm,  which  is 
often  induced  by  an  inflamed  ftate  of  the  knee  and  el- 
bow, and  of  which  we  have  a  very  common  example 
in  thofe  cafes  of  white  fweUing  to  which  thefe  joints 
are  more  particularly  liable.  As  the  Hmb  lies  in  great- 
eft  eafe  while  the  mufcles  are  relaxed,  the  patient  nat- 
urally keeps  it  always  bent ;  and  when  this  pofture  is, 
long  continued,  it  almoft  conftantly  terminates  in  fuch 
a  contracted  ftate  of  the  flexor  tendons,  as  keeps  the 
under  part  of  the  limb  at  an  angle  with  the  fuperior 
part  of  it :  of  this  we  meet  with  daily  inftances  in  the 
leg  ;  where  from  this  caufe  alone  a  patient  is  often  al^ 
together  deprived  of  the  ufe  of  his  limb. 

As  it  has  been  a  prevailing  opinion  among  practi- 
tioners, that  little  advantage  is  to  be  derived  from  any 
remedies  that  we  can  employ  for  diftorted  limbs,  they 
have  feldom  made  any  attempt  to  cure  them :  in  con- 


Chap.  XLI.         Of  Dijioried  Limbs,  443 

fequence  of  which,  this  branch  of"  pra£llce  has  been 
ahnofh  uiiiverfally  trufled  to  itinerants  or  to  profefl'ed 
bonefetters.  In  this,  however,  we  are  wrong  ;  and 
in  faying  fo,  I  can  fpeak  with  confidence,  founded  on 
much  experience :  having  early  in  Hfe  obferved  the 
mifery  to  which  patients  with  diflorted  Hmbs  were  re- 
duced, I  was  refolved  to  make  fome  attempts  for  the 
relief  of  fuch  as  might  apply  to  me,  however  fmall  the 
chance  might  be  of  fucceeding  ;  and  in  various  inftan- 
ces  I  have  had  the  fiitisfaftion  of  relieving,  and  in 
fome  cafes  of  curing  completely,  patients  who  had 
been  lame  for  feveral  years,  and  where  it  was  not  ex- 
pected that  any  thing  could  be  done  for  their  advan- 
tage. Where  an  anchylofis  is  formed  by  the  ends  of 
two  bones  forming  a  joint  having  adhered  together,  it 
would  be  in  vain  to  make  any  attempt  to  remove  it, 
unlcfs  the  inconvenience  attending  it  were  uncommon- 
ly great :  in  which  cafe,  if  it  were  the  patient's  defire, 
this  might  be  a  reafon  for  amputating  the  limb  ;  or  in 
particular  indances,  it  might  be  removed  by  taking 
out  the  ends  of  the  bones  forming  the  joint,  and  al- 
lowing the  newly  divided  ends  of  them  to  unite  to  one 
another  :  but  when  the  fhitfnefs  of  a  joint  depends  on 
a  contracted  ftate  of  the  mufcles  and  tendons  that  ferve 
to  move  it,  by  much  the  mod  frequent  caufe  of  dif- 
torted  limbs,  we  may  almoft  in  every  inftance  aflbrd 
relief  by  more  fimple  means  ;  and  where  a  limb  is 
crooked  by  a  bone  being  bent,  whether  it  may  have 
happened  from  improper  management  during  child- 
hood, or  as  the  effect  of  rickets  or  any  other  difeafe, 
w<f  may  very  commonly,  by  timous  attention,  either 
remove  it  entirely,  or  render  it  much  lefs  confiderable. 
Where  a  limb  is  diflorted  from  a  fliff  contracted 
ftate  of  the  mufcles  and  tendons  that  belong  to  it,  a 
h'iti^  ufe  of  emollients,  with  moderate  gradual  exten- 
fion,  is  the  remedy  from  which  I  have  derived  moft 
advantage,  and  which  never  in  any  inftance  does  harm. 
Thofe  who  have  not  been  in  the  practice  of  ufmg 
emollients  for  this  purpofe,  may  imagine,  that  they 


444  ^f  Di/lorted  Limbs.         Chap.  XLI, 

will  not  penetrate  to  the  depth  of  the  mufcles  and  ten- 
dons ;  and  when  I  firfl:  employed  them,  I  muft  own, 
that  I  did  not  expert  they  were  to  do  fo  in  any  re- 
markable degree  :  but,  knowing  no  other  remedy  that 
was  likely  to  lubricate  fo  effectually  parts  that  were 
become  lliiF,  I  was  refolved  to  give  them  a  complete 
trial  ;  and  I  was  foon  convinced  of  their  utility  :  when 
the  Treatife  on  Ulcers  was  firft  publifhed,  I  had  occa- 
fion  to  mention  this,  and  fince  that  period  very  ample 
opportunities  have  occurred  of  employing  the  fame 
remedy  with  advantage. 

In  order,  however,  to  gain  this  end,  emollients  mufl 
be  ufed  with  great  freedom.  All  the  contracted  muf- 
cles and  tendons,  from  their  origin  to  their  infertion, 
niufl  be  v/ell  rubbed  for  at  lead  half  an  hour  three 
times  a  day ;  and  the  limb  fhould  be  kept  conftantly 
moifl  with,  or  as  it  were  immerfed  in,  the  emollient, 
by  being  covered  with  flannel  well  foaked  in  it  at  ev- 
ery repetition  of  the  frictions.  "While  the  frictions,  are 
applying,  the  limb- fliould  be  flowly,  though  firmly, 
extended  to  as  great  a  degree  as  the  patient  can  eafily 
bear  ;  and  the  inftrument  reprefented  in  Plate  XC. 
may  be  afterwards  applied,  in  order  to  prevent  the 
mufcles  from  contracting. 

It  is  neceffary,  however,  to  remark,  that  this  exten- 
fion  fhould  not  be  made  quickly  :  by  doing  fo,  much 
harm  has  been  done,  infomuch  that  joints  have  become 
pained  and  inflamed,  where  there  was  not  previoufly 
any  other  difeafe  than  fliffnefs  of  the  flexor  mufcles  ; 
while  it  may  be  done  with  the  utmoft  fafety  in  the 
gradual  manner  I  have  mentioned.  In  the  one  way, 
mdeed,  feveral  months  may  be  required  for  effecting 
what  a  greater  force  might  accomplifh  in  as  many 
weeks  ;  but  the  latter  muft  always  be  attended  with 
pain  and  hazard,  while  with  the  other  we  proceed  with 
eafe  and  fafety. 

Even  where  extenfion  is  not  neceffary,  the  effects  of 
emollients  are  often  confpicuous.  We  frequently  meet 
with  fliff  joints,  particularly  in  the  ankle,  without  any 


Chap.  XLI.         Of  Dijlorted  Limbs.  445 

contra£Hon  or  diftortion  of  the  limb.  In  this  cafe, 
emollients  alone,  if  duly  continued,  will  commonly 
relax  them  fufficiently. 

Every  kind  of  greafy  application  proves  ufeful  here, 
but  animal  fats  anfwer  better  than  vegetable  oils.  The 
greafe  of  gcefe  and  ducks  and  other  fowls  anfwers 
well  ;  alfo  hogs  lard,  and  the  oil  obtained  from  boil- 
ing recent  bones  of  beef  and  mutton  in  water.  Butch- 
ers ufually  keep  this  oil  in  quantities  :  when  properly 
prepared,  it  is  quite  pure  and  tranfparent,  and  has  no 
fmell. 

When  the  diftortion  of  a  limb  proceeds  from  a  bone 
being  bent,  if  this  is  not  of  long  duration,  and  efpe- 
cially  when  it  occurs  in  childhood,  we  may  frequent- 
ly remove  or  lefTcn  it  by  conftant  prefiurc  gradually 
increafed  on  the  convex  fide  of  the  limb,  till  the  bone 
is  brought  into  its  natural  diredtion. 

This  kind  of  deformity  often  occurs  in  patients  la- 
bouring under  rickets  ;  but  we  find  it  moit  frequent 
in  new  born  children,  either  from  original  malconfor- 
mation,  or  from  fome  fingularity  in  the  fituation  of 
the  child  while  in  the  womb.  It  is  moft  frequent  irt 
the  legs,  when  it  alfo  affedts  the  dire£lion  of  the  feet 
and  ankles.  When  the  bones  of  the  leg  are  bent  out^ 
ward,  the  foot  is  turned  inward  ;  and,  vice  versa,  th^ 
foot  is  turned  outward  when  the  leg  is  bent  inwards 
Patients  affefted  in  this  laft  manner  are  called  valgi  j 
and  vari  when  the  feet  are  turned  inward. 

Thefe  diftortions  of  the  feet  and  ankles,  have  been 
fuppofed  to  originate  in  almoft  every  inftance  front 
malconformation  in  the  bones  forming  the  joint  of 
the  ankle ;  and  the  means  that  have  been  propofed 
for  removing  them,  have  been  meant  to  produce  an 
alteration  of  that  i(Mnt :  thev  mav  in  fome  cafes  arife 
from  this  caufe,  but  I  have  fcarcely  met  with  it.  At 
firft  view  of  the  difeafe,  we  are  indeed  apt  to  imagine 
that  the  fault  lies  chiefly  in  the  ankle ;  but  it  will  be' 
very  univerfally  found,  as  I  have  juft  obferved,  to  pro- 
ceed fromt  the  form  of  the  leg.    When  the  leg  is  bent 


446i  Of  Dijloried  Limhs.         Cliap.  XLI, 

outward,  the  toes  are  turned  inward,  and  the  fide  of 
the  foot  downward  ;  or,  if  the  curvature  of  the  leg  is 
confiderable,  the  fole  of  the  foot  will  be  turned  near- 
ly altogether  upward,  while  the  top  of  the  foot  will 
refl  on  the  ground  on  every  attempt  to  walk  :  and,  on 
the  contrary,  when  the  bones  of  the  leg  are  bent  in- 
ward, the  toes  and  fole  of  the  foot  will  be  turned  out- 
ward and  upward. 

Whoever  will  examine  with  attention  the  efFed  pro- 
duced upon  the  foot  by  the  bones  of  the  leg  being 
.curved  in  the  manner  I  have  defcribed,  will  find,  that 
the  maladies  we  are  now  confidering  muil  necefl'arily 
refult  from  it ;  and  although  it  may  occafionally  hap- 
pen, that  the  joint  of  the  ankle  is  atFe£ted  by  a  long 
continuance  of  the  diflortion,  yet  in  almoft  every  in- 
ftance,  the  difeafe  will  be  found  to  proceed  originally 
from  the  caufe  I  have  mentioned  :  fo  that  in  the  cure, 
our  views  ihould  be  chiefly  direfted  to  this  afl'eclion  of 
the  leg.  By  removing  the  curvature  of  the  bones,  the 
foot  will  gradually  regain  its  natural  fituation,  while 
all  our  endeavours  will  fail,  if  we  only  attempt  to  al- 
ter the  direction  of  the  ankle  joint. 

When  the  foot  and  toes  are  turned  inward,  folely 
from  a  malconformation  of  the  ankle  joint,  we  ought 
no  doubt  to  endeavour  to  give  the  joint  a  better  direc- 
tion ;  but  as  I  never  met  with  an  inftance  of  this,  I 
mufl:  leave  the  particular  mode  of  effecting  it  to  thofe 
who  may  happen  to  fee  it.  The  befl  method  of  ap- 
plying preffure  to  the  bones  of  the  leg  when  bent,  is 
by  fixing  a  firm  fplint  of  iron  in  the  flioe,  on  the  con- 
cave fide  of  the  leg  ;  and  if  the  head  of  the  fphnt  be 
made  to  reft  againft  the  correfponding  condyle  of  the 
femur,  and  the  other  end  of  it  on  the  foot,  an  eafy 
gradual  preffure  may  be  made  upon  the  oppofite  fide 
of  the  leg,  by  one  or  two  broad  ftraps  paffed  round 
both  the  leg  and  the  fplint.  If  the  fplint  is  covered 
with  foft  leather,  and  properly  fitted  to  the  parts,  it 
gives  no  uneafinefs ;  and  by  drawing  the  ftrap  fur- 
rounding  it  with  the  leg  tighter  from  time  tq  time. 


I 


Chap.  XLI.         Of  Dijloried  Lmhs,  447 

the  preiTure  Is  increafed  in  the  gradual  manner  I  have 
mentioned.  In  Plate  XCIV.  figs.  i.  2.  and  3.  an  ap- 
paratus is  reprcfented  ;  which  in  different  cafes,  where 
the  curvature  of  the  I'^g  was  very  confiderable,  and 
where  the  fole  of  the  foot  was  turned  ahiioft  entirely 
upwards,  anfwered  the  purpofe  completely.  It  proves 
fometimes  fufficient  to  fix  the  fmall  end  of  the  fplint, 
in  the  (lioe,  and  the  broad  flat  pad  at  the  top  on  the 
condyle  of  the  femur.  A  fplint  for  this  purpofe  is  re- 
prcfented in  fig.  2.  This  gives  it  two  fixed  points, 
by  which  we  have  it  in  our  power  to  make  any  necef- 
fary  prefTure  with  the  flraps  paffed  round  the  leg  :  but 
in  fome  inftances,  as  was  the  cafe  in  two  of  thofe  to 
which  I  allude,  the  fole  of  the  foot  could  not  be  kept 
fo  much  down  as  to  admit  of  this,  without  fixing  the 
fhoe  to  a  frame,  as  is  reprefented  in  fig.  3.  for  in  all 
fuch  cafes  the  fole  of  the  foot  (hould  be  kept  as  much 
as  poflible  in  a  natural  fituation,  otherwife  the  preflure 
made  upon  the  leg  for  removing  the  curvature  in  the 
bones  is  apt  to  give  a  wrong  diredion  to  the  joint  of 
the  ankle,  by  the  under  end  of  the  fplint  being  necef- 
farily  made  to  reft  on  it. 

I  have  thus  given  a  general  view  of  the  nature  of 
this  affedion,  and  of  the  management  beft  adapted  for 
removing  it :  but  whether  limbs  are  diftorted  from  a 
contrafted  ftate  of  the  mufcles  that  belong  to  them, 
or  from  a  curvature  in  the  bones,  much  variety  muft 
occur  in  the  application  of  the  remedy,  particularly  in 
the  manner  of  applying  the  extenfion.  The  treatment, 
indeed,  that  fuits  one  cafe  beft,  is  feldom  exadly  ap- 
plicable to  another :  it  muft  therefore  be  varied  ac- 
cording to  the  judgment  of  the  practitioner. 

Other  means  have  been  propoicd  for  removing  cur- 
vatures in  bones  :  of  thefe  the  beft  I  have  feen  is  an 
invention  of  a  late  ingenious  artift  of  this  place,  Mr. 
Gavin  Wilfon,  who  was  long  much  employed  in  this 
branch  of  bufinefs.  In  Plate  XCIII.  fig.  i.  and  2.  I 
have  reprefented  one  of  Mr.  Wilfon's  inftruments  for 
diftortions  of  the  leg. 


44^  Of  Di/loriiom  *Chap.  XLIL 

CHAPTER     XLII. 

OF    DISTORTIONS    OF    THE    SPINE. 

j'TP'HE  fpine  may  be  diftorted  in  various  directions  ; 

1     outwardly,  inwardly,  and  laterally  ;  and  in  fome 

cafes  it  happens  in  all  of  thefe  directions  in  the  fame 

perfon.    This  fometimes  arifes  from  external  violence  ; 

but  more  frequently  as  a  fymptom  of  a  delicate  frame. 

Befides  the  deformity  which  thefe  diftortions  pro- 
duce, they  are  apt  to  injure  the  health,  by  comprefling 
the  abdominal  and  thoracic  vifcera,  and  inducing  pa- 
ralytic affections  of  the  lower  extremities,  in  confe- 
quence  of  the  preiTure  which  they  produce  on  the 
nerves  of  thofe  parts.  They  occur  in  all  ages ;  but 
more  frequently  about  puberty  than  at  any  other  pe* 
riod,  and  more  commonly  in  girls  than  in  boys.  In 
general,  their. effects  are  obferved  before  the  caufe  is 
fufpefted ;  for  there  is  feldoni  much  pain  in  the  dif- 
torted part. 

When  diflortion  of  the  fpine  occurs  during  infancy, 
the  patient  appears  to  be  fuddenly  deprived  of  the  ufe 
of  his  limbs  ;  but  at  more  advanced  periods,  he  com-^ 
plains  firfl  of  feeblenefs  and  languor,  and  of  numbnefs 
or  want  of  feeling  in  the  under  extremities.  By  de- 
grees this  want  of  fenfibility  is  found  to  increafe  ;  and 
he  is  often  obferved  to  (tumble  and  to  drag  his  legs 
inflead  of  lifting  them  cleverly,  nor  can  he  fland  ere6t 
for  any  length  of  time  but  with  much  difficulty.  At 
laft  he  lofes  the  ufe  of  his  legs  entirely,  which  become 
altogether  paralytic  ;  and  when  the  fpine  is  diftorted 
forward,  fo  as  to  comprefs  the  thoracic  and  abdomi- 
nal vifcera,  he  becomes  diftrefied  with  dyfpncea,  or 
■with  complaints  in  the  fl;omach  and  bowels,  according 
to  the  part  of  the  fpine  that  is  difcafcd. 

In  fome  the  lofs  of  power  in  the  extremities  takes 
place  in  the  courfe  of  a  few  days  from  the  lirft  ap- 


Chap.  XLIi.  of  the  Spine.  449 

proach  of  the  difeafe ;  and  it  fometimes  becomes  gra- 
dually lefs,  although  it  never  is,  fo  far  as  I  have  ob- 
ferved,  entirely  removed. 

On  the  deformity  being  difcovered,  we  fometimes 
find  that  one  of  the  vertebra  only  is  difplaced  :  fome- 
times two  or  more  are  affedted  ;  and  in  fome  cafes  it 
appears  to  arife  folely  from  a  thickening  of  the  liga- 
ments connedting  the  vertebrae  together,  without  any 
particular  affedion  of  the  bones.  When  one  of  the 
Vertebrce  only  is  difplaced,  the  patient  is  ufually  more 
completely  deprived  of  the  power  of  his  limbs  than 
when  two  or  more  of  them  are  difplaced,  owing  per- 
haps to  the  angle  being  more  acute,  and  confeqiiently 
the  prcflure  on  the  medulla  fpinalis  more  confiderable 
when  one  bone  only  is  thrown  out  of  the  range.  This 
alio  accounts  for  the  paralytic  fymptoms  being  in  fome 
inftances  lefs  remarkable  in  more  advanced  ftages  of 
the  difeafe  than  they  were  at  firft ;  for  although  one 
bone  only  may  be  difplaced  at  firft,  yet  one  or  both 
of  the  contiguous  vertebras  almoft  conftantly  yield  at 
laft ;  and  the  difference  arifmg  from  this  is  fo  great, 
that  patients  almoft  always  linger  and  die  in  the  courfe 
of  a  year  or  two,  often  in  lefs  time,  when  one  bone 
only  is  deranged  ;  while  they  live  for  a  great  length 
of  time,  frequently  as  long  as  if  no  fuch  circumftance 
had  occurred,  when  the  curvature  of  the  fpine  be* 
comes  more  extcnfive. 

As  diftortions  of  the  fpine  often  proceed  from  deli- 
cate weakly  patients  indulging  too  much  in  particular 
poftures,  every  habit  of  this  kind  fhould  be  avoided 
on  the  firft  appearance  of  the  difeafe.  If  the  patient 
has  been  accuftomed  to  lean  much  to  one  fide,  the  re- 
verfe  of  this  fhould  be  advifed  ;  and  that  the  body 
may  lie  as  much  as  pofTible  upon  an  equal  furface  dur- 
ing fleep,  he  ought  to  ufe  a  hair  mattrefs  laid  upon 
boards  inftead  of  a  bed  of  feathers  or  dov;n. 

By  attention  to  thefe  points ;  by  the  ufe  of  an  invi- 
gorating diet ;  the  cold  bath,  bark,  and  other  tonics  ; 
the  difeafe  has  been  in  fome  cafes  prevented  from  ad- 

Voi..  III.  F  f 


450  Of  Dl/loriions  of  the  Spine,     Chap.  XLII. 

vancing  fo  far  as  it  otherwife  probably  would  have 
done  :  but  where  any  of  the  bones  have  been  affecled, 
I  have  never  feen  an  inflance  of  a  complete  cure  being 
obtained.  Mr.  Pott,  to  whofe  obfervations  upon  this 
fubject  we  are  much  indebted,  fpeaks  highly  of  the  ef- 
fect of  ifl'ues  placed  as  near  as  pdflible  to  the  tumor. 
He  advifes  an  iffue  to  be  opened  with  cauftic  on  each 
fide  of  the  tumor,  large  enough  to  admit  a  kidney 
bean,  and  the  bottom  of  the  fore  to  be  fprinkled  from 
time  to  time  with  powder  of  cantharides.  This  I  have 
praclifed  in  various  cafes,  and  in  fome  inftances  with 
obvious  good  effects  :  but  in  all  of  thcfe  there  was 
reafon  to  fuppofe  that  the  feat  of  the  difeafe  was  in 
the  ligaments  only,  and  not  in  the  bones  of  the  fpine. 
When  they  have  appeared  to  prove  ufeful  where  the 
bones  have  been  affected,  I  conclude  that  the  mitiga- 
tion of  fymptoms  has  arifen  from  the  caufe  I  have 
mentioned,  the  preffure  upon  the  fpinal  marrow  be- 
ing leflened  in  the  progrefs  of  the  difeafe. 

Various  machines  have  been  invented  for  the  re- 
moval of  diftortions  of  the  fpine  by  preffure  :  all  of 
thefe,  however,  do  harm,  and  ought  never  to  be  ufed. 
It  muff  at  once  appear,  to  whoever  is  acquainted  with 
the  anatomy  of  thefe  parts,  and  with  the  nature  of 
this  difeafe,  that  the  difplaced  bone  is  never  to  be  for- 
cibly pufhed  into  its  fituation ;  and  if  this  cannot  be 
done,  it  is  obvious  that  no  advantage  is  to  be  derived 
from  the  practice,  while  it  is  evident  that  much  harm 
may  enfue  from  it. 

In  all  diftortions  of  the  fpine,  it  is  an  object  of  the 
firft  importance  to  fupport  the  head  and  ffioulders. 
If  this  is  negleded,  the  weight  of  the  head  tends  al- 
moft  conftantly  to  increafe  the  curvature.  The  collar 
ufually  employed  for  this  purpofe  anfwers  nearly  as 
well  as  any  other.  In  Plate  CI.  fig.  i.  a  reprefenta- 
tion  is  given  of  one  with  fome  improvements,  by 
which  both  the  head  and  ffioulders  may  be  very  ef- 
fectually fupported ;  and  in  fig.  3.  another  is  deline- 
ated for  fupporting  the  ffioulders  only. 


Chap.  XLIII.  Of  Necrofis.  45 1 


CHAPTER     XLIIL 


OF    NECROSIS. 


TILL  lately  little  was  imderftood  of  this  very  fin- 
gular  difeafe  :  not  from  its  being  new,  or  that 
it  has  only  lately  made  its  appearance,  for  it  feems  to 
depend  on  caufes  that  have  probably  exifted  equally 
in  all  ages  ;  but  from  its  having  been  confounded 
with  other  difeafes,  from  which  however  it  is  widely 
different. 

We  meet  with  many  detached  obfervations  on  this 
difeafe,  in  the  works  of  Hildanus,  Chefelden,  Gooch, 
Hunter  and  others,  but  my  friend  ]\Ir.  Ruffell  was  the 
firft  who  gave  a  regular  fyftematic  account  of  it :  the 
defcription  indeed  that  he  gives  of  it  is  fo  full,  clear, 
and  perfpicuous,  that  fcarcely  any  thing  new  is  left 
for  others  to  add  to  it.* 

The  term  necrofis,  is  derived  from  the  Greek  word 
nekros,  mortuus  ;  in  allufion  to  one  of  the  moll  re- 
markable circumftances  of  the  difeafe,  which  confifts 
in  the  fpontaneous  death  of  one  bone,  and  the  rcpro- 
du(5tion  of  another,  the  laft  of  which  is  in  part  form- 
ed before  the  other  can  feparate. 

The  old  bone,  which  feparates,  and  commonly 
comes  away  either  diflblved  in  the  form  of  matter,  or 
In  one  or  more  pieces,  is  termed  the  fequcftra,  and  it 
is  always  furrounded  by  and  included  in  the  new  one, 
fo  that  the  new  bone  mud  be  larger  in  circumference, 
though  not  longer  than  the  other.  This  being  the 
cafe,  we  would  naturally  fuppofe  that  thofe  tendons 
of  mufcles  which  were  originally  inferted  into  that 

•  Vide  a  Praiflical  EfTay  on  a  certain  difeafe  of  the  bones,  termed 
Necrofis,  illuftrated  with  lix  plates,  by  James  RujTclI,  F.  R.  S.  furgeon, 
Edinburgli. 

F   F  2 


452  Of  Necrofts.  Chap.  XLIII. 

portion  of  the  old  bone  that  is  now  deftroyed,  would 
completely  lofe  their  influence  :  but  it  is  quite  other- 
wife  ;  for  we  find,  that  they  poliefs  their  relative  fitu- 
ation  in  the  newly  formed  bone,  into  which  they  are 
inferted  by  the  oihfication  of  a  gelatinous  fluid  poured 
forth  around  them.  The  new  bone  which  is  thus 
produced,  appears  to  be  poflclfed  of  all  the  eflfential 
properties  of  the  original.  It  is  not  indeed  fo  regular 
in  its  external  appearance,  nor  internal  ftruclure,  for 
it  is  not  lamellated,  but  it  can  fet  out  oflific  granula- 
tions ;  it  may  exfoliate,  and  it  performs  all  the  func- 
tions peculiar  to  an  original  bone. 

From  all  the  experiments  and  obfervations  that  have 
hitherto  been  made  on  the  fubjeft,  it  feems  to  be  pro- 
bable that  the  periofleum  is  no  way  concerned  in  the 
production  of  the  new  bone ;  that  it  does  not  furnifli 
granulations  for  its  increafe  ;  that  defliruction  of  the 
marrow  does  not  naturally  follow  an  attack  of  necro- 
fis  ;  but  that  this  procefs  never  takes  place  without  a 
previous  fl:ate  of  inflammation. 

The  fymptoms  attending  necrofis  are  the  following  : 
Firft,  there  is  a  deep  feated  pain  in  the  limb ;  and  in- 
flammation and  fuppuration  take  place  :  the  matter 
thus  formed  difcharges  itfelf  in  one  or  more  openings 
in  the  moil  prominent  parts  of  the  limb,  and  thefe 
openings  communicate  with  fmufes  that  commonly  go 
to  the  depth  of  the  bone  :  the  matter  for  the  mofl 
part  is  good,  though  copious,  and  it  cannot  be  in- 
creafed  in  quantity  by  prefiiire. 

The  fequefl:ra  is  not  always  difcovered  by  the  probe, 
and  the  fore  fometimes  heals  without  the  former  be- 
ing thrown  off" ;  at  other  times,  however,  when  the 
inflammation  is  fevere,  the  fequefl:ra  is  thrown  oflf 
quickly,  which  commonly  excites  a  temporary  lofs  of 
power  of  the  whole  limb  :  but  in  general  the  inflam- 
mation is  flight ;  the  procefs  of  feparation  goes  on 
flowly  ;  and  the  patient  retains  the  motion  and  ufe  of 
his  limb. 


Chap.  XLIII.  Of  Necrcfts.  453 

In  the  courfe  of  the  difeafe,  the  fores  frequently 
heal  and  break  out  again,  and  holes  form  in  the  new- 
ly formed  bone  correfponding  with  the  fmous  open- 
ings on  the  furface  :  it  has  been  found,  that  in  this 
difeafe  even  joints  are  regenerated,  and  in  that  cafe 
the  cartilage  is  always  larger  than  in  the  original  fe- 
queftra  ;  this  has  taken  place  in  the  lower  jaw,  where 
new  fockets  are  formed  for  the  teeth  which  have  been 
retained. 

The  progrefs  of  necrofis  is  always  tedious ;  in  fome 
it  will  be  over  in  the  courfe  of  a  few  months  ;  but  in 
a  great  proportion  of  cafes  it  goes  on  for  two  or  three 
years. 

We  chiefly  meet  with  necrofis  in  infancy  and  early 
youth,  and  more  frequently  in  the  lower  jaw  and  in 
the  bones  of  the  leg  than  in  any  other  part  of  the 
body. 

ITie  mofl  obvious  predifpofmg  caufes  of  necrofis 
are  lues  venerea,  and  a  fcrofulous  diathefis  ;  and  in 
fome  inflanccs  we  can  trace  the  exciting  caufe  to  an 
external  accident,  as  a  blow  or  a  bruife. 

The  difeafes  for  which  necrofis  may  be  miflaken 
are  the  following  :  caries  of  a  bone  produced  by  in- 
flammation or  colledions  of  matter  without  expofure 
to  the  external  air  ;  and  it  may  be  miftaken  for  the 
exfoliation  of  an  external  lamella  of  a  bone :  but  in 
the  latter  the  internal  furface  is  fmoother,  the  matter 
is  thin  and  fetid,  and  the  granulations  lefs  firm  and* 
more  extenfive  than  in  necrofis. 

The  danger  arifing  from  necrofis  is  In  a  great  mea- 
fure  to  be  eifimatcd  from  the  degree  of  inflammation 
and  fever  that  takes  place  :  it  feldom  proves  danger- 
ous, and  where  thefe  fymptoms  are  moderate,  the  pa- 
tient is  able  in  a  great  proportion  of  cafes  to  conduct 
his  ordinary  bufinefs  without  confinement  ;  but  when 
he  becomes  heftic,  as  fometimes  happens,  immediate 
amputation  of  the  limb  is  perhaps  the  only  remedy  to 
be  trufl:ed. 


454  Of  Necrofis.  Chap.  XLIII. 

In  the  cure  of  necrofis,  no  general  treatment  proves 
of  any  avail,  and  there  is  reafon  to  think,  \vhen  the 
fequeilra  feparates  eafily,  that  the  interference  of  art 
fhould  never  be  advifed.  If  it  be  not  indeed  in  cer- 
tain circumftances,  it  is  perhaps  our  beft  practice  to 
do  nothing  in  the  whole  courfe  of  the  difeafe  but  to 
obviate  particular  fymptoms. 

When  the  pain  is  fevere,  local  bloodletting  and  the 
general  effects  of  antiphlogidic  remedies,  as  I  have  al- 
ready obferved,  are  to  be  chiefly  depended  on.  When 
matter  is  formed  and  is  found  to  lodge  in  any  of  the 
foft  parts  of  the  limb,  it  ought  to  be  difcharged  by 
fmall  openings,  and  the  ftrength  of  the  patient  re- 
quires to  be  fupported  by  due  attention  to  a  well  re- 
gulated diet,  as  otherwife  it  is  apt  to  fmk  by  the  long 
duration  of  the  difeafe. 

In  this  manner  a  cure  is  frequently  obtained  with- 
out any  farther  affiftance  from  art,  that  is,  the  fequef- 
tra  either  diifolves  and  comes  away  infenfibly  in  the 
matter  difcharged  from  the  fore ;  or  it  comes  ofl:'  in 
one  or  more  pieces  ;  or  the  irritation  that  it  excites 
becomes  inconfiderable,  and  the  fores  at  laft  heal, 
while  the  fequeftra  ftill  continues  furrounded  with  the 
newly  formed  bone.  The  limb  is  larger  than  the  oth- 
er, and  commonly  fomewhat  deformed  by  the  inequal- 
ities on  the  furface  of  the  bone ;  but  under  thefe  in- 
conveniencies  the  patient  fometimes  efcapes  without 
•much  pain,  and  with  little  or  no  injury  to  his  confti- 
tution. 

It  fometimes,  however,  happens,  that  the  fequeftra 
does  not  come  away,  while  at  the  fame  time  it  creates 
fo  much  irritation,  that  fever  takes  place,  by  which, 
and  by  a  profufe  difcharge  of  matter  from  the  fores, 
the  health  of  the  patient  is  brought  into  hazard :  in 
this  fituation,  an  attempt  jfhould  either  be  made  to  re- 
move the  fequeftra  by  a  chirurgical  operation,  or  im- 
mediate amputation  of  the  limb  ftiould  be  advifed. 

If  any  part  of  the  fequeftra  appears,  it  may  be  right 
to  endeavour  to  fave  the  limb  by  taking  it  away  j  but 


Chap.  XLIIL  Of  Vecrofis.  455 

where  no  part  of  the  old  bone  is  dlfcovered,  under 
all  the  uncertainty  of  the  exacl  fituation  and  flate  in 
which  it  may  be,  together  with  the  rifk  of  increafing, 
by  this  operation  the  ftate  of  irritation  over  the  whole 
limb,  it  will  probably,  in  the  courfe  of  further  expe- 
rience, appear  to  be  our  bed  pradice,  in  fuch  circum- 
ftances,  to  advife  the  limb  to  be  amputated. 

The  operation  for  removing  the  fequeflra  is  done 
in  the  following  manner :  a  longitudinal  incifion  is 
made  through  all  the  foft  parts  covering  the  difeafed 
bone  :  in  this  manner  the  bone  mud  be  laid  complete- 
ly bare,  but  if  the  teguments  are  found,  no  part  of 
them  fhould  be  removed. 

If  the  fequeflra  is  difcovered  by  any  holes  in  the 
newly  formed  bone,  and  if  thefe  are  very  near  to  one 
another,  an  opening  fufficiently  large  for  taking  it  out 
may  be  made  with  a  large  fcalpel  or  a  fliarp  chifel 
and  mallet ;  but  it  fhakes  the  limb  lefs,  and  gives  Icfs 
pain  to  the  patient,  to  do  it  with  reiterated  applica- 
tions of  the  trephine,  and  afterwards  to  cut  out  with 
a  firm  fcalpel,  fuch  fmall  portions  of  the  bone  as  the 
faw  may  have  left.  In  the  event  of  no  opening  in  the 
new  bone  being  met  with,  fmall  holes  may  be  drilled 
in  it  with  the  perforator  of  a  trepan.  In  this  manner 
the  ftate  of  the  fequeftra  may  be  difcovered,  when  by 
the  operation  that  I  have  already  defcribed,  with  the 
head  of  the  trepan,  an  opening  may  be  made  in  the 
new  bone  of  a  fufficient  fize  for  removing  the  other. 
This,  however,  as  I  have  already  obferved,  is  an  ope- 
ration neceflarily  attended  with  uncertainty  and  haz- 
ard, fo  that  in  a  great  proportion  of  cal'es,  it  will  pro- 
bably be  found  to  be  a  fafer  practice'  to  amputate  the 
limb. 

After  the  fequeftra  is  removed,  mild  dreflings  fliould 
be  applied  :  emollient  poultices  and  an  antiphlogiftic 
regimen  prove  ufeful,  while  fymptoms  of  inflamma- 
tion take  place  ;  by  which,  and  a  due  attention  to 
regimen,  the  fore  will  heal  eafily,  when  the  health  is 


45^  Of  Necrofts,  Chap.  XLIII, 

othervvlfe  good :  the  cure  however  proves  always  te- 
dious, bemg  fcldom  completed  in  lefs  than  fix  months, 
and  as  the  limb  fhould  be  kept  during  the  whole  pe- 
riod at  perfect  reft,  and  as  much  as  poflible  in  the 
fame  pofition,  the  confinement  is  necelTurily  of  the 
moft  diftrefsful  nature. 

This,  together  with  the  uncertainty  and  hazard  of 
the  operation  for  removing  the  fequeftra  when  no 
part  of  it  appears,  makes  me  conclude,  as  I  have  ob- 
ierved  already,  that  in  all  fuch  circumftances  it  is  per- 
haps our  beft  pradice  rather  to  amputate  the  limb. 


Seel.  I.  Remarks  on  Amputat'tGn*  457 


CHAPTER     XLIV. 

OF    AMPUTATION. 

SECTION     I. 

General  Remarks  o?i  the  Operation  of  Ampidaiicn, 

Y  the  term  amputation,  we  ufually  underftand 
the  removal  of  the  whole  or  part  of  a  hmb.  We 
fpcak  of  the  extirpation  of  a  tumor  ;  of  the  mamma  ; 
of  a  teftis  :  but  we  fay  the  amputation  of  a  leg  and 
of  an  arm. 

The  mutilation,  produced  by  this  operation,  renders 
it  one  of  the  mod  dreadful  in  the  pradice  of  furgery  ; 
yet  as  the  only  means  by  which  life  can  be  faved,  it  is 
frequently  neceflary.  It  is  an  operation,  however,  fo 
repugnant  to  humanity,  fo  diflrefsful  to  the  unfortu- 
nate fufl'erer,  and  in  fome  circumftances  fo  fraught 
with  danger,  that  nothing  but  a  clear  convidion  of 
this  neceility  can  warrant  our  propofing  it  in  any  cafe. 

The  operation,  indeed,  is  not  difficult :  every  prac- 
titioner accullomed  to  handle  inflruments  may  perform 
it.  But  to  diftlnguifh  with  precifion  the  cafes  which 
require  it,  from  thofe  Vvhich  might  do  well  under  a 
different  treatment,  and  to  determine  the  particular 
periods  of  each  when  it  ought  to  be  performed,  are 
circumftances  which  require  more  deliberation  than 
perhaps  any  other  in  furgery  :  I  fhall  therefore  enu- 
merate the  caufes  which  may  render  amputation  ne- 
ceflary, before  proceeding  to  defcribe  the  method  of 
performing  it. 


458^  Of  Caufes  that  render      Chap.  XLIV. 

SECTION    II. 

Of  the  Caufes  ivhich  may  render  Amputation  neceffary. 

THIS  operation  may  be  rendered  neceflary  by  va- 
rious caufes  ;  all  of  which  may  be  comprehend- 
ed under  the  following  heads. 
I.  Bad  compound  fractures. 

I.  Extenfive  lacerated  and  contufed  wounds. 

3.  A  portion  of  a  limb  being  carried  off  by  a  cannon 
ball,  or  in  any  other  manner,  if  the  bones  are  un- 
equally brokeYi  and  not  properly  covered. 

4.  Extenfive  mortification. 

5.  White  fwellings  of  the  joints. 

6.  Large  exoftofes,  whether  they  are  confined  to 
joints,  or  fpread  over  the  whole  bone  or  bones  of 
a  limb. 

7.  Extenfive  caries,  accompanied  with  bad  ulcers  of 
the  contiguous  foft  parts. 

8.  Cancer,  and  other  ulcers  of  an  inveterate  nature. 

9.  Various  kinds  of  tumors. 

1  o.  Particular  diflortions  of  a  limb. 

II.  Necrofis. 

Each  of  thefe  caufes  I  fliall  confider  in  the  order  in 
which  they  are  mentioned. 

In  Chapter  XXXIX.  Sedion  XVI.  I  had  occafion 
to  fpeak  particularly  of  compound  fractures  :  I  fhall 
at  prefent  therefore  only  remark,  as  the  fubftance  of 
what  was  then  fully  pointed  out,  that  in  the  army  and 
navy,  v/here  ordinary  patients  cannot  be  duly  attend- 
ed, and  where  they  muft  be  much  jolted,  and  often 
removed  from  place  to  place,  immediate  amputation 
fhould  be  advifed  in  all  cafes  of  bad  compound  frac- 
tures. Cafes  will  often  indeed  occur  even  in  the  worfl 
fituations,  in  which  it  will  be  improper  to  amputate 
the  limbs.  Thus,  where  little  violence  has  been  done, 
and  where  the  bones  have  been  broken  fo  much  in  a 


Seel.  II.  Amputation  necejfary.  459 

tranfverfe  direftion,  that  when  replaced  they  fupport 
each  other  with  firmnefs,  and  efpecially  if  one  bone 
only  is  broken,  it  would  no  doubt  be  a  fevcre,  and 
often  an  unneceflary  nieafure,  to  propofe  the  removal 
of  the  limb.  But  whenever  much  violence  has  been 
done  to  a  limb  ;  when  the  bones  are  broken  in  fuch 
a  manner  that  they  do  not,  even  when  exadly  replac- 
ed, fupport  each  other  firmly,  and  when  the  ilefhy 
parts  that  cover  them  are  much  torn ;  in  all  fuch  fit- 
uations,  I  confider  it  as  a  good  general  rule  to  advife 
immediate  amputation.  Unlefs  the  operation,  how- 
ever, can  be  performed  foon  after  the  accident,  it  can- 
not again  be  admiflible  for  a  confiderable  time  ;  for 
whenever  a  limb  has  become  fwelled  and  inflamed,  it 
can  never,  but  with  the  utmofl  danger,  be  taken  ofl' 
till  thefe  fymptoms  fubfide. 

In  private  praftice,  however,  where  the  patient  can 
from  the  fi)fl  be  placed  in  an  eafy  comfortable  fitua- 
tion,  from  which  he  need  not  be  removed  till  his  cure 
iv5  completed  ;  where  he  can  be  kept  perfectly  quiet, 
and  have  all  the  advantages  of  good  air,  a  proper  reg- 
imen, and  the  alliftance  of  able  practitioners,  very  few 
cafes  will  occur  in  which  immediate  amputation  Ihould 
be  advifcd.  The  only  caufe,  as  I  have  elfewhere  ob- 
ferved,  which  in  fuch  circumftances  can  render  imme- 
diate amputation  proper,  is  the  bones  of  a  limb,  togeth- 
er with  the  mufcles  and  other  foft  parts  with  which  it 
is  covered,  being  fo  fhattered  and  bruifed  that  there 
will  be  no  chance  of  the  limb  being  rendered  ufeful 
by  any  attempt  that  might  be  made  to  fave  it :  in  fuch 
eircumftances,  it  fliould  be  removed  immediately  ;  but 
this  not  being  done,  the  operation,  as  I  have  obierved 
above,  fliouId  be  delayed,  till  the  fwelling,  inflamma- 
tion, and  fever  induced  by  the  accident,  are  removed. 

Although  early  amputation,  however,  is  feldom  ne- 
ceffary  in  private  praftice,  yet,  in  the  after  treatment 
of  compound  fraftures,  it  is  fometimes  proper  : 

I.  In  confequence  of  profufe  hemorrhagies  which 
cannot  be  otherwife  flopped.     Thefe  fometimes  hap* 


460  Of  Caufes  that  render     Chap.  XLIV. 

pen  from  one  or  more  arteries  being  cut  by  the  ends 
of  the  fracbured  bones,  as  well  as  from  other  caufes. 

2.  In  confequence  of  extenfive  mortification.  This 
we  fliall  have  occafion  to  confider  more  particularly 
in  fpeaking  of  mortification  as  one  of  the  general  caul- 
es  of  amputation. 

And,  3.  By  the  ends  of  the  fractured  bones  remain- 
ing long  difunited,  attended  with  the  difcharge  of  fuch 
large  quantities  of  matter,  that  the  patient  runs  fome 
rifk  of  finking  under  it. 

I  have  elfevvfhere  obferved,  that  the  union  of  frac- 
tured bones  is  fometimes  prevented  by  a  loofe  portion 
of  bone  being  left  which  ought  to  have  been  remov- 
ed ;  and  nothing  more  readily  keeps  up  a  profufe  dif- 
charge of  matter  :  but  when  all  fuch  pieces  of  bone 
have  been  removed ;  when  no  union  takes  place ;  or 
when  the  difcharge  dill  continues  in  fuch  quantities  as 
to  weaken  the  patient  notwithitanding  of  all  that  can 
be  done  to  prevent  it ;  fuch  as  preferving  the  limb 
fteadily  in  one  pofture,  regular  dreffing  of  the  fore,  a 
nouriiliing  diet,  and  a  plentiful  ufe  of  bark  ;  nothing 
vvill  in  fuch  circumftanccs  fo  certainly  fave  the  patient 
as  the  removal  of  his  limb. 

1.  I  mentioned  extenfive  laceration  and  contufed 
wounds  as  the  fecond  general  caufe  of  amputation. 
Wounds  not  accompanied  with  fraftures  of  the  con- 
tiguous bones  are  feldom  fo  bad  as  to  require  ampu- 
tation in  any  ftage  of  them  :  but  when  a  limb  is  fo  fe- 
verely  lacerated  or  contufed  as  to  have  all  the  large 
blood  velfels  that  belong  to  it  deftroyed,  fo  as  to  leave 
no  ground  of  hope  that  the  circulation  can  be  preferv- 
ed  in  it,  immediate  amputation  iliould  be  advifed, 
whether  the  bone  is  fafe  or  not.  As  in  fuch  circum- 
ftances  no  effort  on  the  part  of  the  practitioner  could 
fave  the  limb  ;  and  as  wound,s  of  this  defcription  are 
more  apt  to  terminate  in  mortification  than  any  other, 
the  fooiier  the  operation  is  performed  the  better. 

It  will  alfo  happen  in  lacerated  and  contufed  wounds, 
that  amputation  may  be  afterwards  neceifary,  although 


Sed.  II.  Amputation  necejfary,  461 

it  did  not  appear  to  be  fo  at  firft.  In  this  refpe£l  they 
are  limilar  to  compound  fradures,  and  the  Tame  ob- 
fervations  will  apply  to  them.  Hemorrhagies  may 
occur  which  cannot  be  flopped  ;  extenfive  mortifica- 
tion may  take  place  ;  and  fuch  large  quantities  of 
maft^  VQSff  form,  that  the  patient  will  not  be  able  to 
bear  up  under  the  dilcliarge.  In  any  of  thefe  events, 
we  have  to  confider  the  removal  of  the  Hmb  as  the  on- 
ly remedy. 

3.  The  removal  of  a  portion  of  a  limb  by  a  cannon 
ball  or  other  violence,  was  mentioned  as  the  third  gen- 
eral caufe  of  amputation. 

This  is  one  of  thofe  cafes  which  many  contend  can 
never  require  amputation  :  for  the  limb  being  already 
removed,  it  will  be  better,  they  allege,  to  endeavour 
to  heal  the  fore,  than  to  add  to  the  pain  and  danger 
of  the  patient  by  an  operation.  The  argument  is  plau- 
fible,  but  it  will  not  bear  examination. 

In  wounds  of  this  kind,  the  bones  are  commonly 
much  fhattered,  and  even  fplintered  ;  and  the  mufcles 
and  tendons  are  left  of  unequal  lengths,  and  much 
lacerated  and  contufed.  In  this  fituation  it  is  allowed 
by  all,  that  the  feparate  pieces  of  bone,  as  well  as  the 
fliarp  ends  of  the  remaining  bone,  fliould  be  removed, 
toccether  with  the  rapeed  extremities  of  the  mufcles 
and  tendons.  Now  all  this  could  feldom,  I  believe, 
be  done  in  lefs  time  than  the  operation  of  amputation  ; 
while  by  amputating  above  the  injured  part,  and  cov- 
ering the  bone  with  found  mufcles  and  Ikin,  we  di- 
miniih  the  fore  fo  much  that  it  would  probably  heal 
in  a  third  part  of  the  time  that  the  original  wound 
would  require  ;  at  the  fame  time  that  the  patient  will 
have  a  good  ftump,  which  in  the  other  method  never 
could  be  the  cafe  :  with  me  this  lafl  argument  of  it- 
felf  Vv'ould  be  fufHcient  for  advifmg  the  operation  un- 
der the  circumflances  we  are  confidering  :  for,  as  I 
do  not  fuppofe  it  would  add  to  the  danger,  any  addi- 
tional momentary  pain  it  might  occafion,  would  be 
amply  compenfatcd  by  the  advantage  he  would  after- 


462  Of  Caufcs  that  render     Chap.  XLIV. 

wards  derive  from  it.  When  the  praftitioner  has  it 
in  his  power,  the  operation  fhould  be  advifed  immedi- 
ately ;  for,  however  neceflary  it  might  be,  many  pa- 
tients would  not  afterwards  have  fufficient  firmnefs  of 
mind  to  fubmit  to  it  ;  and,  from  ignorance  of  the  ad- 
vantages to  be  derived  from  it,  would  prefer  prefent 
eafe,  to  future  conveniency  and  advantages,  however 
great  they  might  be. 

4.  Mortification  is  the  next  caufe  we  have  to  con- 
fider  by  which  amputation  may  become  neceflary. 
They  w^ho  are  determined  to  oppofe  the  pradice  of 
amputation  as  much  as  poffible,  affect  to  confider  it  as 
unnecefl'ary  even  in  mortification  :  all  the  lelfer  degrees 
of  it,  they  obferve,  may  be  cured  ;  and  when  very  ex- 
tenfive,  the  patient,  they  allege,  will  commonly  fall  a 
facrifice  to  the  difeafe,  whether  the  operation  is  per- 
formed or  not.  This  opinion,  however,  is  fo  direclly 
contrary  to  fa£l:,  and  to  the  experience  of  every  un- 
prejudiced practitioner,  that  I  need  not  attempt  to  re- 
fute it :  for  although  it  w^ould  be  highly  improper  to 
advife  the  removal  of  a  limb  in  flight  degrees  of  gan- 
grene ;  yet  when  mortification  has  fpread  fo  extenfive- 
ly  as  to  defliroy  all  or  even  a  great  proportion  of  the 
foft  parts  of  a  limb,  an  occurrence  too  frequently  met 
with,  what  remedy  could  be  employed  inftead  of  it  ? 
As  I  know  of  none,  and  as  I  never  heard  of  any  that 
in  any  way  could  prove  ufeful,  I  fliall  conclude,  that 
in  mortification  proceeding  to  fuch  an  extent  as  I  have 
mentioned,  amputation  of  the  limb  becomes  indifpen- 
fable. 

But  although  this  do£trine  will  be  generally  admit- 
ted, yet  practitioners  are  not  agreed  with  refpeft  to 
the  period  of  mortification  at  which  the  operation 
fliould  be  performed.  Some  contend,  that  in  almofl: 
every  cafe  of  gangrene,  and  efpecially  where  it  pro- 
ceeds from  external  violence,  the  limb  fliould  be  am- 
putated as  foon  as  mortification  is  evidently  formed, 
and  while  it  continues  to  fpread  :  others  are  of  o])In- 
ion,  that  amputation  fliouId  never  be  advifed  till  the 


Se£t.  II.  Afiiputation  neccjfary.  463 

gangrene  is  not  only  flopped,  but  till  the  gangrenous 
parts  are  feparated  from  the  found. 

Thofe  who  advife  immediate  amputation  obferve> 
that  by  taking  the  limb  ofl'  above  the  difeafed  part,  we 
may  prevent  the  progrefs  of  the  mortification,  and  may 
thus  fave  the  patient.  Although  the  argument  is  fpe- 
cious,  it  does  not  appear  to  be  well  founded  ;  and  fo 
far  as  my  obfervation  goes,  I  would  fay  that  it  is  a 
practice  fraught  with  danger,  and  ought  univerfally  to 
be  difcarded  :  for  however  attentive  we  may  be  in  am- 
putating at  a  part  of  the  limb  that  appears  to  be  found, 
even  the  mod  experienced  practitioner  will  be  liable 
to  be  deceived.  The  (kin  may  be  perfedly  found,  and 
may  be  free  from  pain,  inflammation,  and  fwelling  ; 
and  yet  the  deep  feated  mufcles,  and  other  parts  con- 
tiguous to  the  bone,  may  be  in  a  ftate  of  gangrene. 
Of  this  I  have  feen  various  inftances  :  but  even  where 
the  whole  divided  parts  are  found  to  be  entirely  found, 
if  the  operation  is  performed  while  mortification  is  ad- 
vancing, the  difeafe  feldom  fails  of  feizing  the  flump  ; 
at  lead,  I  never  knew  an  inftancc  of  the  contrary,  and 
I  have  unfortunately  been  concerned  in  different  cafes 
where  this  pradice  was  adopted.  On  converfing  with 
practitioners,  who,  from  peculiarity  of  fituation,  have 
much  employment  in  thofe  accidents  which  are  moft 
apt  to  terminate  in  gangrene,  1  alfo  find  that  their  ex- 
perience tends  to  fupport  this  opinion  :  it  was  alfo 
the  decided  opinion  of  the  late  Mr.  Sharpe,  and  Mr. 
Pott,  and  of  every  modern  practitioner  of  obfervation.* 
I  think  it  right  to  mention  this,  as  attempts  have  of 
late  years  been  made  by  fome  fpeculative  practitioners 
to  introduce  a  contrary  practice  ;  which  if  admitted, 
there  is  much  reafon  to  fufpeCt  would  prove  extreme- 
ly hurtful,  although  from  its  proving  fo  univerfally 

•  Mr.  Pott's  words  upon  this  point  arc  very  ftronj^ :  "  I  have  more 
*  tlian  once  fctii  tlie  cxptriincnt  made  of  amputating  after  a  gangrene 
"  lias  been  begun  ;  but  I  never  law  it  fucceed  :  it  has  always  hurried  the 
"  patient ■»  dcftruCtion."     Vide  Remarks  on  Fradures,  &c. 


464  Of  Caufes  that  render     Chap.  XLlV* 

unfuccefsful,  there  is  reafon  to  hope  that  it  will  foon 
be  laid  afide,  even  by  thofe  who  at  prefent  patron- 
ize it. 

I  would  not  think  it  neceffary,  however,  to  delay 
the  operation  fo  long  as  is  advifed  by  fome,  and  par- 
ticularly by  Mr.  Sharpe  ;  who  thinks  that  it  Ihould 
never  be  performed  till  the  feparation  of  the  mortified 
parts  is  coniiderably  advanced.*  As  Mr.  Sharpe  was 
a  man  of  much  experience,  his  obfervation  may  prove 
to  be  well  founded ;  but  fo  far  as  I  have  yet  feen,  I 
would  confider  it  as  fufficient  to  wait  till  the  mortifi- 
cation is  completely  flopped,  but  not  much  longer : 
in  this  manner,  v^e  feem  to  reap  all  the  advantages 
which  the  caution  that  I  have  adviicd  can  give  ;  and 
the  earlier  after  this  that  the  mortified  parts  are  remov- 
ed, the  more  readily  we  prevent  the  fyftem  from  fuf* 
fering  by  the  abforption  of  that  putrefcent  matter  which 
a  gangrenous  mafs  univerfally  yields. 

The  opinion  that  I  have  given  relates  to  every  vari- 
ety of  gangrene.  In  whatever  w^ay  it  may  have  arif- 
en,  the  practice  fhould  be  the  fame  :  for  although  fome 
ftrefs  has  been  commonly  laid  upon  the  circumftance 
of  its  proceeding  from  an  internal  or  external  caufe, 
yet  no  utility  is  derived  from  this.  The  operation 
fhould  in  no  inftance  be  advifed  till  the  period  I  have 
mentioned  ;  and  at  that  time,  whatever  may  have  been 
the  caufe  of  the  difeafe,  no  delay  fhould  be  admitted. 

tj.  In  mentioning  white  fwellings  of  the  joints  as  a 
caufe  of  cftnputation,  I  mufl  refer  to  Chapter  II.  Sec- 
tion III.  §  I  o,  for  the  management  of  the  difeafe,  as 
well  as  for  a  more  particular  account  of  thofe  fymp- 
toms  that  more  efpecially  indicate  the  operation.  At 
prefent  I  have  only  to  obferve,  that  as  long  as  there 
is  the  leaft  reafon  to  hope  that  by  any  means  the  limb 
may  be  faved  without  hazard  to  the  patient,  the  ope- 
nition  fliould  never  be  advifed.  As  a  farther  motive 
for  this,  I  may  remark,  in  addition  to  what  I  have  in 

•  vide  Treatife  on  the  Operations  of  Surgery,  Chapter  xxxvii. 


Sed.  II.  Amputation  necejfary,  465 

various  parts  of  this  work  done  already,  that  amputa- 
tion, more  frequently  fucceeds,  that  is,  a  greater  pro- 
portion recover  from  the  operation  when  it  is  delayed 
till  the  patier^t  is  confiderably  reduced  by  the  difeafe, 
than  when  it  is  performed  in  the  more  early  part  of 
it.  The  caufe  of  this  may  be  nearly  the  fame  as  what 
I  have  given  in  Chapter  XXXIX.  Section  XVI.  when 
advifing  late  amputation  in  fome  circumilances  of 
compound  fractures. 

6.  In  Chapter  II.  Se6lion  III.  I  entered  upon  the 
confideration  of  the  various  kinds  of  exoflofis  ;  fo  that 
at  prefent  I  have  only  to  remark,  that  when  a  difeaf- 
ed  portion  of  bone  cannot  be  taken  out  in  the  manner 
I  have  formerly  advifed,  and  when  the  tumor  is  eith- 
er hurting  the  patient's  health  or  has  become  unfup- 
portable  from  its  fize  or  any  other  circumftance,  am- 
putation of  the  limb,  when  no  particular  reafon  pre- 
vents it,  fhould  be  advifed  as  the  only  remedy. 

7.  The  next  caufe  that  I  have  mentioned  of  ampu- 
tation, is  an  extenfive  caries  attended  with  ulcers  of 
the  contiguous  parts.  AVhen  fpeaking  of  caries,  in 
the  feventh  Sedlion  of  Chapter  V.  I  pointed  out  the 
different  means  employed  for  the  cure  of  the  difeafe, 
that  is,  for  promoting  an  exfoliation  of  the  difeafed 
part  of  the  bone.  In  addition  to  what  I  had  then  oc* 
cafion  to  fay,  it  may  be  obferved,  that  although  an 
extenfive  caries  is  in  general  confidered  of  itfelf  as  a 
fufficient  reafon  for  amputating  a  limb,  yet  it  certain- 
ly Ihould  be  admitted  under  much  reilridlion.  How- 
ever extenfive  a  caries  may  be,  even  although  it  occu- 
pies the  whole  length  of  a  bone,  it  may  be  in  many 
inftances  removed  ;  and  we  have  many  on  record  of 
deficiencies  produced  in  this  manner  being  amply  fup- 
plied  by  a  regeneration  of  bone :  fo  that  where  the 
conditution  is  found,  and  more  efpecially  when  the 
patient  is  young,  a  carious  bone  will  feldom  of  itfelf 
be  a  fufficient  motive  for  removing  a  limb,  at  leall  the 
chance  of  faving  it  by  removing  the  difeafed  bone 

Vol.  III.  G  g 


456  Of  Caufes  that  render     Chap.  XLIV.. 

fhould  firfl  be  given.  But  when  a  carious  bone  is  con- 
oined  with  deep  and  extenfive  ulcers  of  the  corre- 
fponding  foft  parts,  which  might  give  much  caufe  to 
fufped  that  a  cure  would  not  be  obtained  even  al- 
though the  difeafed  bone  fliould  be  taken  out,  ampu- 
tation fhould  be  preferred ;  for  in  this  fituation,  be^ 
fides  the  difficulty  of  healing  the  fores,  the  formation 
of  any  confiderable  quantity  of  bone  would  be  very 
uncertain,  and  therefore  the  rifk  fhould  not  be  in- 
curred. 

8.  The  next  caufe  to  which  we  have  to  advert,  by 
which  amputation  may  become  necelfary,  is  cancer, 
and  other  ulcers  of  an  inveterate  nature. 

When  fpeaking  of  cancer  in  Chapter  V.  Sedion 
VIII.  I  endeavoured  to  fhow,  that  no  dependence  is  to 
be  placed  either  upon  internal  medicines  or  outward 
applications  for  a  cure ;  and  that  the  removal  of  the 
difeafed  part  is  alone  to  be  trufted.  It  mufl  be  ac- 
knowledged that  cancer  does  not  frequently  occur  in 
the  extremities  :  but  every  practitioner  muft  have  feen 
it  on  different  parts  of  them  ;  and  wherever  it  appears, 
the  removal  of  the  difeafed  parts  with  the  knife  fhould 
be  advifed  immediately.  They  may  be  often  taken 
away  without  amputating  the  limb  ;  but  when  the  dif- 
eafe  has  attacked  the  ligaments  or  bones,  and  efpe- 
cially  when  the  fore  is  extenfive,  nothing  but  the  re- 
moval of  the  limb  above  the  parts  difeafed  ought  to 
be  trufted.  In  fuch  circumitances,  I  have  known  at* 
tempts  made  to  fave  the  limb,  but  never  with  fuccefs. 
Even  the  removal  of  the  limb  will  fometimes  fail ; 
but  I  have  known  it  anfwer  where  the  difeafe  had  re- 
turned after  being  removed  in  the  ufual  way. 

Befides  cancer,  other  ulcers  may,  in  particular  clr- 
cumftances,  render  amputation  neceffary :  where  an 
extenfive  ulcer,  not  induced  by  any  general  alfedion 
of  the  fyftem,  is  hurting  the  health  of  a  patient ;  and 
when,  inftead  of  yielding  to  the  ufual  remedies,  it  be- 
comes more  extenfive  and  more  inveterate,  as  it  might 
at  laft  proceed  io  far  as  to  endanger  life,  wc  ought 


Se£l:.  II.  Amputation  nece[faryi,  467 

rather  to  advife  the  limb  to  be  taken  off.  Such  ulcers 
as  are  ufually  termed  phagadenic,  fometimes  ternunate 
in  this  fatal  manner :  but  this  termination  is  mod  fre- 
quent in  fniuous  ulcers  ;  fuch  as  arife  from  deep  feat- 
ed  abfcefles,  where  the  matter  has  found  accefs  be- 
tween the  interftices  of  the  large  mufcles,  and  where, 
notwithftanding  all  our  endeavours,  the  difcharge  con- 
tinues to  be  fo  proful'e  as  to  endanger  the  life  of  the 
patient. 

9.  Various  kinds  of  tumors  may  render  amputa- 
tion neceflary. 

Encyfted  tumors  feldom  lead  to  this  neceflity ;  but 
in  fome  inilanccs  where  they  are  deep  feated,  origin- 
ating pei;haps  from  the  periolleum,  when  they  are  al- 
lowed to  remain  till  they  acquire  a  great  bulk,  all  the 
contiguous  parts  come  to  be  fo  much  injured,  that 
nothing  but  the  removal  of  the  limb  will  anfwer  any 
good  purpofe.  In  fome  cafes,  by  long  continued  pref- 
lure  from  the  tumor,  the  contiguous  bones  not  only 
become  carious,  but  are  altogether  diifolved  ;  at  the 
fame  time  that  the  cellular  fubftance,  and  even  the 
mufcles  of  the  limb,  become  fo  much  difeafed  as  to 
give  no  caufe  to  hope  that  we  could  be  able  to  fave 
them.  ► 

We  fometimes  find  a  portion  of  a  limb  confiderably 
enlarged,  with  an  uniform  hardnefs  in  fome  parts,  and 
in  others  3.  degree  of  foftnefs  that  gives  caufe  to  fuf- 
pedl  that  a'  fluid  is  collected  beneath.  The  (kin  at 
hrfl  retains  its  natural  colour ;  but  at  laft  acquires  a 
livid  hue.  The  commencement  of  the  difeafe  is  not 
attended  with  pain  ;  but  at  laft  it  not  only  becomes 
painful,  but  extremely  troublefome  from  its  weight. 
It  ufually  begins  without  any  evident  caufe,  and  often- 
in  people  who  are  otherwife  healthy  :  at  firft  the  fwell- 
ing  commonly  appears  on  the  inferior  part  of  a  limb, 
and  proceeds  gradually  up  till  it  occupies  the  whole 
of  it. 

o  G  2 


468  Of  Caufes  that  render     Chap.  XLIV. 

This  kind  of  fwelling  is  at  firfl:  often  miflaken  for 
common  oedema  or  anafarca  ;  and  feems  to  be  fo  far 
of  this  nature,  that  it  is  evidently  produced  by  efFu- 
fion  into  the  cellular  fubflance :  but  inflead  of  being 
of  the  ferous  kind,  the  effufed  fluid  is  found  to  be 
tinged  with  blood,  and  of  an  acrimonious  nature  ;  at 
leaft  this  has  been  the  cafe  in  all  that  I  have  known 
opened  :  and  it  has  likewife  happened,  that  the  mat- 
ter has  never  been  difcharged  in  fuch  quantities  as  to 
have  much  influence  on  the  fize  of  the  tumor,  the 
fwelling  ufually  remaining  of  nearly  the  fame  bulk 
after  the  operation  as  it  was  before  :  hence  no  advan- 
tage is  derived  from  it ;  on  the  contrary,  the  opera- 
tion very  commonly  does  harm.  A  painful  fore  is 
produced  ;  and  it  always  accelerates  the  progrefs  of 
the  tumor.  Indeed,  nothing  that  I  have  ever  known 
employed  has  any  eftecl  in  retarding  it ;  fo  that  I  con- 
lider  amputation  as  the  only  refource,  whenever  the 
tumor  has  become  fo  large  as  to  give  much  uneafi- 
nefs.  Whether  it  will  always  prove  effectual  or  not, 
I  cannot  pretend  to  fay  ;  but  hitherto  I  have  met  with 
jio  inftance  of  the  difeafe  returning  where  amputation 
was  performed  on  a  found  part  of  the  limb. 

SwelKngs  of  the  aneurifmal  kind  have  alfo  been 
confidered  as  a  caufe  which,  in  particular  fituations, 
may  give  rife  to  amputation.  This  has  originated 
from  the  operation  for  the  aneurifm  having  failed  in 
different  inflances  when  performed  upon  the  crural 
artery,  and  from  the  amputation  of  the  limb  having  in 
fimilar  affedtions  faved  the  life  of  the  patient.  When 
an  aneurifm  in  the  ham  or  the  thigh  is  large,  and  has 
been  of  fuch  long  duration  as  to  hurt  the  texture  of 
the  foft  parts,  as  well  as  to  injure  the  bone,  which  ef- 
fufed blood  is  apt  to  do,  it  will  no  doubt  be  better  to 
amputate  the  Hmb  than  to  niake  any  attempt  to  fave 
it :  but  in  fuch  a  cafe,  it  is  not  the  aneurifm  for  which 
amputation  is  advifed,  but  a  morbid  (late  of  the  parts, 
induced  by  the  difeafe  being  allowed  to  continue  too 
long  before  any  eifedual  meafure  is  adopted.     In  the 


Sed.  II.  Atnputation  necejfarj,  469 

commencement,  and  for  a  confiderable  time  thereaf- 
ter, of  tlie  femoral  or  poplitean  aneiirifm,  I  fhould 
never  advife  the  amputation  of  a  limb  :  for  different 
inftances  are  on  record  of  limbs  being  faved  by  the 
operation  for  the  aneurifm,  even  where  the  artery  was 
injured  in  the  fuperior  part  of  the  thigh  :  but  where 
fuch  an  extenfive  oedematous  fwelling  is  induced  all 
over  the  under  part  of  a  limb,  as  to  leave  no  room  to 
hope  that  it  could  again  be  reftored  to  ufe,  even  al- 
lowing the  operation  for  the  aneurifm  to  fucceed,  it 
will  no  doubt  be  better  to  amputate  immediately  than 
to  attempt  the  operation. 

The  aneurifm  to  which  I  allude,  is  that  which  pro- 
ceeds from  a  dilatation  of  the  artery,  and  in  which  the 
coats  of  the  veflel  have  burft,  fo  as  to  produce  a  con- 
fiderable effufion  of  blood  into  the  furroundiug  cellu- 
lar fubftance,  probably  before  any  proper  affillance  is 
defired.  This  w-ill  feldom  happen  but  with  the  poor- 
efl  clafs  of  people  j  and  therefore  this  difeafe,  in  the 
ftate  we  are  now  fpeaking  of,  is  chiefly  found  in  hof- 
pitals.  At  full  it  is  always  attended  with  a  flrong 
pulfation  ;  but  in  its  latter  ftages  the  fwelling  becomes 
fo  large,  that  the  beating  of  the  artery  is  fcarcely,  if  at 
all  dilcovered  ;  by  which  it  is  apt  to  be  miftaken  for 
a  tumor  of  a  different  kind  :  but  for  the  mod  part,  a 
due  attention  to  the  hiftory  of  the  cafe  from  the  be- 
ginning, will  lead  to  a  knowledge  of  its  real  nature. 

The  I  oth  general  caufe  that  I  enumerated,  by  which 
amputation  may  become  neceffary,  is  particular  dillor- 
tions  of  a  limb. 

Where  a  limb  is  in  other  refpeds  perfedly  found, 
it  will  feldom  happen  that  any  diftortion  to  which  it 
is  liable  will  be  confidered  as  a  fufficient  reafon  for 
this  operation :  but  in  the  courfe  of  much  bufmefs, 
cafes  are  fometimes  met  with  in  which  limbs  are  fo 
much  diftorted,  and  produce  fo  much  diftrefs,  that 
patients  rather  incline  to  have  them  removed  than 
fubmit  longer  to  the  inconvenience.  When  in  fuch 
circumflances  we  are  not  able  to  remove  the  dillor- 


47 o  General  Remarks  Chap.  XLIV. 

tion  by  means  of  a  more  gentle  nature,  we  are  in  fomc 
cafes  obliged  to  comply  with  the  patient's  requeft. 

II.  Certain  flates  of  necrofis  may  render  amputa- 
tion neceflary,  as  may  be  feen  in  Chapter  XLIII. 

Thefe  are  the  feveral  caufes  by  which  the  amputa- 
tion of  a  limb  may  be  rendered  neceflary.-  As  they 
are  very  various,  and  as  the  lofs  of  a  member  is  to 
every  patient  an  obje£t  of  much  importance,  they 
merit,  in  every  inftance,  the  utmoft  attention  from 
practitioners.  Indeed  this  point  of  pradice,  namely, 
that  of  fixing  with  precifion  thofe  cafes  in  which  the 
amputation  of  limbs  (hould  be  advifed,  with  the  moft 
fuitable  periods  for  the  operation  in  each,  is  attended 
with  fuch  difficulty,  and  a  furgeon  is  fo  apt  to  be  bla- 
med if  he  proceeds  to  the  operation  fo  long  as  there 
is  the  fmallefl  doubt  of  its  being  neceffary,  that  it 
fhould  be  held  as  a  fixed  regulation  with  every  prac- 
titioner, never  to  operate  but  with  the  advice  of  fome 
of  his  brethren  in  confultation,  when  this  can  poflibly 
be  obtained.  I  fhall  now  proceed  to  defcribe  the  me- 
thod of  operating. 


SECTION    III. 

General  Remarks  on  the  Method  of  Amputating  Limbs. 

SUrgery  is  not  perhaps  in  any  part  of  it  brought 
to  greater  perfection  than  in  the  method  of  am- 
putating limbs.  Before  the  invention  of  the  tourni- 
quet, this  operation  v/as  attended  with  fo  much  haz- 
ard, that  few  furgeons  ventured  to  perform  it  :  nay, 
long  after  the  introduction  of  this  inftrument,  the  dan- 
ger attending  it  was  fo  great,  that  more  than  one  half 
perifhed  of  all  who  had  refolution  to  fubmit  to  it. 

In  the  prefent  improved  flate  of  the  operation,  I  do 
not  imagine  that  one  death  will  happen  in  twenty  ca- 
fes ;  even  including  the  general  run  of  hofpital  prac- 


Seft.  III.  en  Amputation*  47 1 

tice  :  and  In  private  pradice,  where  due  attention  can 
be  more  certainly  bellowed  upon  the  various  circum- 
ftances  of  the  operation,  the  proportion  of  deaths  will 
be  much  lefs. 

The  circumftances  in  this  operation  that  more  par- 
ticularly require  attention,  are,  the  choice,  when  this 
is  in  our  power,  of  the  part  at  which  a  limb  fhould  be 
amputated  ;  the  prevention  of  hemorrhagy  during  the 
operation  ;  the  divifion  of  the  (kin,  mufcles,  and 
bones,  in  fuch  a  manner  as  to  admit  of  the  Hump  be- 
ing completely  covered  ;  the  tying  of  the  arteries 
alone,  without  including  the  nerve  or  any  of  the  con- 
tiguous parts  :  fecuring  the  teguments  in  a  proper 
fituation,  fo  as  to  prevent  their  retra£lion  after  the 
operation  ;  and  a  proper  fubfequent  treatment  of  the 
cafe. 

Next  to  fecuring  the  patient  from  lofs  of  blood,  the 
moft  material  of  thefe  is  the  faving  of  fuch  a  propor- 
tion of  the  foft  parts  as  will  cover  the  ftump,  fo  as  to 
heal  the  fore  as  nearly  as  pofTible  by  the  firfl  intention  : 
for  without  this,  the  wound  produced  by  the  removal 
of  a  lai^ge  limb  is  always  extenfive ;  the  cure  accord- 
ingly proves  tedious  ;  and  the  difcharge  fo  copious, 
that  the  patient's  health  is  by  this  caufe  alone  irrepar* 
ably  injured. 

The  inconveniencles  arlfmg  from  this  were  fo  obvli 
ous,  that  various  attempts  were  made,  from  time  to 
time,  to  improve  this  part  of  the  operation.  At  firfl:, 
all  that  was  done  in  amputating  a  limb,  was  to  cut  the 
foft  parts  down  to  the  bone  by  one  ftroke  of  a  knife, 
and  afterwards  dividing  the  bone  with  the  faw  at  the 
edge  of  the  retraced  mufcles.  It  was  afterwards  pro- 
pofed  by  Mr.  Chefelden  to  divide  the  foft  parts  by  a 
double  incifion  ;  to  divide  the  ikin  and  cellular  fub- 
ftance  with  a  circular  incifion  ;  and  then  to  cut 
through  the  mufcles  at  the  edge  of  the  retra£led  (kin : 
by  this  means  the  faw  was  applied  higher  in  the  bone, 
and  the  flump  was  better  covered  both  with  mufcles 


472  General  Remarks         Chap.  XLIV. 

and  (kiri.  Still,  however,  an  extenfive  fore  was  left ; 
infomuch  that  in  amputating  the  thigh,  a  cure  was 
feldom  performed  in  lefs  than  three  or  four  months  ; 
often  five  or  fix  were  required  ;  and  after  all,  the 
flumps  were  commonly  pyramidal,  by  the  bone  pro- 
je6ling  beyond  the  foft  parts  :  it  often  happened  too, 
that  another  fore  was  produced  by  this  part  of  the 
bone  exfoliating,  long  after  the  patient  confidered 
himfelf  as  perfeftly  well. 

To  prevent  this  pyramidal  or  fugar  loaf  (lump,  as 
it  is  termed,  a  bandage  or  circular  roller  was  employ- 
ed, with  a  view  to  fupport  the  mufcles  and  teguments, 
and  to  prevent  their  retradion ;  and  when  properly 
applied  from  the  upper  part  of  the  limb  downwards, 
it  in  fome  degree  aniwcred  the  purpofe,  but  never  with 
fuch  effe6l  as  to  prevent  the  cure  fj-om  being  tedious. 
In  order  to  fhorten  it  farther,  it  was  propofed  by  the 
late  Mr.  Sharpe,  in  his  Treatife  on  this  Operation,  to 
draw  the  teguments  near  together  by  flitches  or  pieces 
of  tape  palTed  through  them,  and  tied  acrofs  the  Hump  : 
but  the  pain  and  inconvenience  arifing  from  this  was 
fo  great,  that  it  never  was  generally  practifed  ;  and 
Mr.  Sharpe  himfelf  at  lall  defifted  from  it. 

It  was  now  thought  impofTible  to  improve  this  meth- 
od of  operating,  fo  as  to  fhorten  the  cure,  and  in  place 
of  a  pyramidal  flump,  to  give  the  fore  a  plain  furface. 
In  confequence  of  this,  about  forty  years  ago,  differ- 
ent furgeons  attempted  to  revive  v/hat  was  termed  the 
flap  operation  ;  which  had  been  firft  praftifed,  upwards 
of  a  hundred  years  ago,  by  an  Englifh  furgeon  of  the 
name  of  Loudham.  It  was  done  by  faving  a  flap  of 
the  mufcles  and  fkin,  in  the  manner  I  fhall  afterwards 
defcribe,  laying  the  flap  over  the  flump,  and  fecuring 
it  in  this  fituation  with  proper  bandages  till  it  united 
to  the  parts  beneath. 

As  this  afforded  a  thick  mufcular  cufhion  to  the 
flump  as  well  as  a  complete  covering  of  found  fkin, 
the  highefl  expectations  were  formed  of  it :  but  the 


Sea,  III.  071  Jmpufatloti.  473 

objections  to  it,  which  I  fhall  afterwards  mention,  were 
fo  great,  that  the  utmoft  exertions,  even  of  expert  fur- 
geons,  to  render  it  more  perfed:,  have  not  been  able 
to  introduce  it  to  general  ufe. 

This  failure  again  excited  the  attention  of  practition- 
ers to  the  improvement  of  the  common  operation  of 
amputation  ;  and  their  endeavours  have  not  proved 
unfuccefsful.  By  the  prefent  improved  method  of 
operating,  fo  much  of  the  teguments  are  faved  as  com- 
pletely covers  the  (lump  ;  by  which,  in  fome  inftan- 
ces,  a  cure  is  obtained  by  the  firft  intention  without 
the  formation  of  matter  :  and  in  all,  unlefs  there  is 
fomething  particularly  bad  in  the  habit  of  body,  or 
unlefs  the  inilammation  unexpectedly  runs  to  a  very 
unufual  height,  a  cure  is  completed  in  the  courfe  of  a 
few  weeks.  As  I  confider  the  improvement  by  which 
thefe  ends  are  efi'eded  as  one  of  the  molt  important 
in  modern  practice,  I  hope  to  be  excufed,  if  I  fliortly 
ftate  the  fhare  I  have  had  in  the  introduction  of  it,  be- 
fore proceeding  to  defcribc  the  operation  itfelf. 

In  the  courfe  of  my  education,  while  attending  the 
hofpital  here,  as  well  as  the  hofpitals  of  London  and 
Paris,  the  inconveniencics  arifmg  from  the  want  of  at- 
tention to  the  faving  of  fkin  in  different  chirurgical 
operations,  ftruck  me  (trongly  ;  fo  that  I  v/as  refolvtd 
to  take  every  proper  opportunity  in  my  own  practice, 
of  treating  this  point  with  particular  attention. 

From  the  year  1772,  when  I  fettled  in  bufmefs,  I 
laid  it  down  as  a  maxim,  not  to  be  deviated  from,  to 
fave  as  much  fivin  and  cellular  fubftance  in  the  remov- 
al of  tumors,  whether  cancers  or  others,  when  the 
foundnefs  of  part  admitted  of  it,  as  would  completely 
cover  the  fores  ;  and  in  amputating  any  of  the  extrem- 
ities to  fave  as  much  of  them  as  would  entirely  cover 
the  flumps.  I  firlt  performed  amputation  in  the  courfe 
of  that  year ;  and  finding  the  improvement  of  faving 
fkin  to  anfwer  even  beyond  my  expectation,  (for  the 
cure  of  a  large  flump  in  an  amputation  of  the  thigh 


474  0?:  Amputaiing  Chap.  XLIV. 

was  completed  in  three  weeks,)  I  did  not  fail  of  put- 
ting it  afterwards  in  practice  both  in  pubhc  and  pri- 
vate. The  pra£lice  was  hkewife  adopted  by  my  friend 
IVIr.  Hay  of  this  place,  and  more  lately  by  fome  other 
gentlemen  in  their  attendance  at  the  hofpital ;  and  ev- 
er fmce  that  period,  Mr.  Hay,  I  believe,  and  I,  have 
invariably  adhered  to  it,  fome  deviations  being  occa- 
llonally  introduced  in  the  mode  of  doing  it,  with  a 
view  of  rendering  it  more  perfeft  ;  by  which  the  cures 
have  in  every  inllance  been  greatly  fhortened.  In  va- 
rious'cafes,  large  flumps  which  by  the  ufual  method 
would  have  required  feveral  months,  were  cured  in  as 
many  weeks  :  in  a  few,  as  was  obferved  above,  the 
parts  united  by  the  firfl  intention  j  and  in  all,  a  plain 
uniform  ftump  was  produced. 

After  this  had  been  praclifed  for  feveral  years,  Mr. 
Alanfon  of  Liverpool,  in  the  year  1779,  publiflied 
fome  Obfervations  upon  Amputation,  in  which  a  me- 
thod of  operating  is  defcribed,  v^hich  he  recommends 
in  the  warmefl  manner,  as  anfwering  every  objeft  to 
be  expected  from  this  operation  ;  and  more  efpecially, 
that  of  curing  the  flumps  in  a  great  meafure  by  the 
firfl  intention. 

As  Mr.  Alanfon's  mode  of  operating  has  of  late 
been  very  defervedly  preferred  to  every  other  that  was 
before  publifhed,  I  fhall  afterwards  give  an  account  of 
it ;  but  in  the  mean  time,  1  fhall  defcribe  that  which 
I  have  long  been  accuflomed  to  praftife,  and  which, 
after  various  trials  of  every  other  of  which  I  have  yet 
heard,  I  itill  continue  to  prefer.  In  the  firfl  place,  I 
fhall  defcribe  the  operation  as  it  is  performed  upon  the 
thigh,  and  fhall  afterwards  fpeak  of  the  method  of 
amputating  other  parts  of  the  extreniities. 


Sea.  IV.  the  Thigh,  475 

SECTION     IV. 

Of  Amputating  the  Thigh, 

IN  amputating  either  the  thigh  or  leg,  the  patient 
fliould  be  placed  upon  a  table  of  an  ordinary  height, 
with  the  leg  properly  fecured  and  fupported  by  an  af- 
fiftant  fitting  before  him.  The  other  leg  fhould  like- 
wife  be  fupported,  at  the  fame  time  that  the  arms 
fhould  be  fecured  by  an  afliflant  on  each  fide,  to  pre- 
vent interruptions  during  the  operation. 

The  flow  of  blood  to  the  limb  fliould  now  be  flop- 
ped by  the  application  of  the  tourniquet,  in  the  man- 
ner I  have  mentioned  in  Chapter  VII.  and  as  it  is  of 
importance  to  have  the  inflrument  placed  as  near  as 
poffible  to  the  top  of  the  thigh,  the  cufhion  placed  up- 
on the  femoral  artery  fhould  reach  the  groin. 

This  is  neceffary  when  the  operation  is  to  be  per- 
formed on  the  upper  part  of  the  limb ;  but  it  may 
likewife  be  done  with  fafety  where  it  is  to  be  taken 
off  immediately  above  the  knee  :  and  I  may  here  ob- 
ferve,  with  refpedt  to  the  mod  proper  place  at  which 
a  thigh  fhould  be  amputated,  that  no  more  of  it  fhould 
be  taken  away  than  is  rendered  neceffary,  by  the  dif- 
eafe  j  for  the  more  of  it  that  is  left,  the  more  ufeful 
it  proves. 

An  alfiftant  fhould  now  be  direfted  to  grafp  the  up- 
per part  of  the  limb  with  both  hands,  and  to  draw  up 
the  ikin  and  cellular  fubflance  as  far  as  pofTiblc.  While 
the  parts  are  in  this  flate  of  tenfion,  the  operator,  Hand- 
ing on  the  outfide  of  the  patient,  fhould  divide  them 
with  a  circular  incifion  down  to  the  mufcles  :  this  may 
in  general  be  done  with  one  llroke  of  the  amputating 
knife,  fig.  3.  Plate  XCVIII.  but  in  large  limbs  it  is 
eafier  done  at  twice.  The  afliflant  continuing  to  draw 
the  teguments  upwards,  the  cellular  fubflance  con- 
necting them  to  the  mufcles  beneath,  fhould  be  divid- 


47^  Of  Ampuiating  Chap.  XLIV. 

ed  with  the  edge  of  the  knife  till  as  much  of  the  fl-:in 
is  feparated  as  the  operator  thinks  will  completely  cov- 
er the  flump. 

The  fkin  being  ftill  drawn  tightly  upwards,  the 
mufcles  fliould  be  divided  clofe  to  the  edge  of  it  down 
to  the  bone,  by  one  perpendicular  and  continued  flroke 
of  the  knife,  beginning  with  the  upper  part  of  the 
large  mufcles  on  the  infide  of  the  thigh,  and  continu- 
ing the  incifion  round  through  thofe  beneath,  and  on 
the  outfide  till  it  terminates  where  it  commenced. 
During  this  part  of  the  operation,  fome  attention  is 
neceifary  to  avoid  the  edge  of  the  retraded  (kin  ;  but 
it  may  always  be  done  if  the  operator  is  upon  his 
guard,  for  he  may  with  little  difficulty  have  his  eye 
upon  the  courfe  of  the  knife  from  firfl:  to  laft  ;  nor 
can  this  part  of  the  operation  be  done  with  fafety  in 
any  other  manner.  Even  where  different  afliftants  are 
employed  to  proted  the  Ikin,  it  will  be  apt  to  be 
wounded,  if  the  operator  does  not  at  every  point  fol- 
low the  knife  with  his  eye. 

In  the  ufual  method  of  operating,  the  bone  would 
now  be  fawn  acrofs  at  the  edge  of  the  retracted  muf- 
cles :  but  we  are  more  certain  of  having  a  good  flump, 
if  the  mufcles  are  previoufly  feparated  from  the  bone 
for  the  fpace  of  an  inch  ;  and  it  is  eafily  done  by  in- 
fer ting  the  point  of  the  amputating  knife  between  them, 
and  carrying  it  freely  round  from  one  fide  of  the  limb 
to  the  other.  This  being  done,  the  mufcles  and  teg- 
uments muft  be  drawn  up  as  far  as  the  mufcles  have 
been  feparated  from  the  bbne  ;  and  it  is  eafily  done, 
either  with  a  bit  of  flit  leather,  fuch  as  is  reprefented 
in  Plate  XCVIL  fig.  4.  or  with  the  iron  retradors  in 
the  fame  Plate,  fig.  2.  and  3.  The  periofteum  fhould 
now  be  divided  at  the  place  where  the  faw  is  to  be  ap- 
plied, and  it  fhould  be  done  with  one  turn  of  the 
knife  ;  for  where  much  of  it  is  fcraped  off,  very  tedi- 
ous and  troublefome  exfoliations  are  apt  to  enfue  :  the 
knife  fhould  therefore  be  carried  round  the  bone  di- 
redly  beneath  the  retradors.     At  this  place  the  faw 


I 


Sea.  IV.  the  TJj'igh.  477 

{hould  be  applied,  and  with  long  fteady  flrokes  the 
bone  fhould  be  divided.  Thefaw  represented  in  Plate 
XCVIII.  fig.  I.  anfwers  much  better  than  the  ufual 
form  of  the  inftrument  with  a  heavy  iron  back.  In 
performing  this  part  of  the  operation,  the  affiflant  hold- 
ing the  leg  fhould  be  diredled  to  fupport  it  fteadily  ; 
for  if  raifed  too  far,  the  motion  of  the  faw  will  be  im- 
peded, while  the  bone  will  be  apt  to  be  fplintered  if 
it  be  not  fufficiently  raifed.  Any  points  or  fplinters 
that  may  be  left,  fliould  be  immediately  removed  with 
the  nippers,  Plate  XLIII.  fig.  2. 

The  retradors  ihould  now  be  taken  off;  and  the 
trunk  of  the  femoral  artery  being  eafily  feen,  fhould 
be  drawn  out  with  a  tenaculum,  and  a  fuflicient  hga- 
ture  made  upon  it  before  the  tourniquet  is  loofened  : 
but  as  the  mufcular  branches  of  this  artery  cannot  be 
difcovered  as  long  as  they  are  comprefled,  the  fcrew 
fhould  be  immediately  untwifted,  fo  that  the  prefl'ure 
may  be  entirely  removed.  All  the  clotted  blood  fhould 
be  now  removed  from  the  flump  with  a  foft  fponge 
foaked  in  warm  water  ;  and  every  artery  that  can  be 
difcovered  fhould  be  fecured  with  a  ligature,  care  be- 
ing taken  to  leave  the  ends  of  the  threads  of  a  fufficient 
length  to  hang  over  the  lips  of  the  wound. 

The  blood  veffels  being  all  fecured,  and  the  furface 
of  the  wound  cleared  of  blood,  the  mufclcs  and  tegu- 
ments fhould  be  drawn  down  till  the  fkin  completely 
covers  the  ftump,  and  fliould  be  retained  in  this  fitu- 
ation  by  an  affiitant  till  a  flannel  or  cotton  roller,  pre- 
vioufly  fixed  round  the  body  to  prevent  it  from  flip- 
ping down,  is  applied  in  fuch  a  manner  as  to  fupport 
and  fix  them  :  tor  which  purpofe  the  roller  fliould  be 
pafl'ed  two  or  three  times,  nearly  in  a  circular  direc- 
tion, round  the  top  of  the  thigh  ;  and  fliould  after- 
wards, with  fpiral  turns,  be  brought  down  near  to  the 
end  of  the  flump,  of  fuch  a  tightnefs  as  to  prevent  the 
niufcles  and  fkin  from  retracing,  without  comprcfling 
them  fo  much  as  to  proAe  painful,  or  to  impede  the 
circulation.     Here  the  roller  fhould  be  fixed  with  a 


478  Of  Amputating  Chap.  XLIV., 

common  pin,  while  as  much  of  it  is  left  as  will  pafs 
two  or  three  times  round  the  flump,  for  a  purpofe  ta 
be  prefently  mentioned. 

The  ends  of  the  divided  mufcles  being  placed  with 
as  much  equality  as  poiTible  over  the  bone,  the  edges 
of  the  fliin  mufi:  be  laid  exadlly  together,  fo  as  to  form 
a  flraight  longitudinal  line  along  the  centre  of  the 
(lump.  When  only  one  or  two  arteries  have  been  fe- 
cured,  the  ligatures  fhould  be  left  out  at  the  inferior 
angle  of  the  wound  \  but  when  there  are  feveral,  they 
fhould  be  divided  between  the  two  angles,  to  prevent 
the  parts  from  fuftering  by  a  large  extraneous  body 
fixed  at  any  one  place. 

While  an  aiTiftant  retains  the  edges  of  the  divided 
fkin  in  contacl,  two  or  three  flips  of  adhefive  plafter 
fhould  be  laid  acrofs  the  face  of  the  flump,  to  preferve 
them  in  this  fituation  ;  and  the  whole  furface  of  the 
flump  fliould  now  be  covered  with  a  large  pledget  of 
foft  lint,  fpread  with  faturnine  cerate,  or  the  common 
calamine  cerate  of  the  Difpenfatories :  over  this  there 
Ihould  be  placed  a  foft  cufhion  of  fine  tow  with  a  com- 
prefs  of  old  linen.  For  the  purpofe  of  retaining  them, 
as  well  as  with  the  view^  of  making  gentle  preflbre  up- 
on the  flump,  a  flip  of  linen,  of  three  inches  in  breadth, 
fhould  be  laid  over  them  ;  fo  as  to  pafs  dire6lly  acrofs, 
and  not  from  above  downwards.  On  being  properly 
placed,  the  remaining  part  of  the  roller  fliould  be  em- 
ployed to  fix  it,  by  pafTmg  it  two  or  three  times  round 
the  flump  ;  and  the  preflTure  formed  by  the  crofs  flrap 
may  afterwards  be  increafed  or  diminifhed,  by  draw- 
ing  it  with  more  or  lefs  tightnefs,  and  fixing  it  with 
pins  to  the  circular  roller. 

In  applying  the  roller,  the  tourniquet  fhould  be  re- 
moved, and  replaced  immediately  when  the  flump  is 
dreffed.  If  left  loofe,  it  gives  no  uneafmefs  ;  and  it 
enables  the  attendants  to  check  any  hemorrhagy  that 
may  take  place  ;  a  circumflance  that  merits  attention 
for  feveral  days  after  amputation  of  any  of  the  ex- 
tremities. 


Sea.  IV.  the  Thi^h.  479 

The  patient  fhould  now  be  carried  to  bed  ;  but  in- 
ftead  of  raifing  the  flump  to  a  confiderable  height  with 
pillows,  as  is  ufually  done,  it  fhould  be  laid  fomewhat 
lower  than  the  refl  of  the  body  :  for  this  purpofe,  the 
bed  fliould  be  previoufly  made  with  a  gentle  declivity 
from  above  downwards,  and  nothing  fliould  be  put 
beneath  the  flump  but  fuie  tow. 

To  prevent  the  patient  from  moving  the  limb  inad* 
vertently,  as  well  as  to  guard  in  fome  meafure  againft 
the  eft'ecl:  of  thofe  fpafms  which  often  prove  trouble- 
fome  after  this  operation,  I  commonly  employ  two  flips 
of  flannel  to  fix  the  flump  down  to  the  bed.  It  is  ea- 
fily  done,  by  laying  one  acrofs  near  the  extremity  of 
the  flump,  and  another  near  to  the  root  of  the  thigh. 
They  fhould  be  pinned  to  the  circular  roller  round 
the  limb  ;  and  the  ends  of  each  of  them  fhould  be 
pinned  to  the  bed  :  or  they  may  be  tied  to  it  with  pie- 
ces of  fmall  tape  previoufly  fewed  to  the  bed,  or  to  the 
mattrefs,  which  anfwers  better  than  a  feather  bed  for 
any  patient  to  be  long  confined.  A  bafket  or  hooped 
frame  fhould  now  be  put  over  the  flump,  to  protect 
it  from  the  bedclothes  ;  and  whether  the  patient  com- 
plains much  or  not,  I  make  it  a  conflant  rule  to  give 
him  an  anodyne,  by  which  he  remains  quiet  and  eafy 
through  the  remainder  of  the  day,  inflead  of  being 
refllefs  and  diftreffed,  which  he  is  otherwife  apt  to  be. 

As  hemorrhagies  will  fometimes  happen,  even  many 
hours  after  the  operation,  the  attendant  taking  charge 
of  the  patient  fhould  be  flricl:ly  enjoined  to  examine 
the  flump  frequently  with  the  utmofl  care ;  and  on 
any  quantity  of  blood  breaking  out,  to  twift  the  tour- 
niquet fufficiently  tight,  till  afliflance  is  procured.  I 
think  it  right,  however,  to  obferve,  that  in  general  it 
is  the  fault  of  the  pra6litioner  when  this  very  perplex- 
ing occurrence  takes  place ;  for  it  feldom  happens 
when  the  arteries  are  fearched  for  in  the  time  of  the 
operation  with  that  accuracy  which  the  importance  of 
the  fituation  requires.  Indeed,  hemorrhagies  are  lefs 
frequent  after  this  method  of  operating,  than  when  the 


480  Of  Amputating  Chap.  XLIV. 

mufcles  are  left  uncovered  ;  and  this  is  one  material 
advantac^e  that  refults  from  it :  for  however  attentive 
a  furgeoii  may  be  in  fecuring  the  arteries,  the  irrita- 
tion produced  upon  an  extenfive  wound,  and  the 
fpafms  that  enfue,  very  frequently  terminate  in  fatal 
hemorrhagies.  Of  this  I  have  known  feveral  inftan- 
ces  ;  while  no  difcharge  of  any  importance  has  ever 
happened  in  the  method  of  operating,  of  which  I  have 
thus  given  a  defcription.  I  believe  too,  as  I  have  eife- 
where  remarked,  that  fome  additional  lecurity  is  de- 
rived from  the  uie  of  the  tenaculum :  for  although 
thofe  who  have  not  been  in  the  habit  of  ufmg  it,  are 
apt  to  confider  it  as  more  uncertain  than  the  needle, 
yet  it  is  far  from  being  fo.  I  will  not  fay  that  hemor- 
rhagies will  never  enfue  where  the  tenaculum  is  em- 
ployed ;  but  it  has  fo  happened  in  the  courfe  of  my 
obfervation,  that  the  needle  was  ufed  in  every  cafe  of 
hemorrhagy  that  proved  fatal. 

Where  there  is  only  a  trivial  oozing  of  blood,  we 
need  not  be  alarmed ;  nor  will  it  be  necellary  to  re- 
move the  dreflings  :  but  whenever  the  difcharge  is  fo 
confiderable  as  to  give  caufe  to  fufpeft  that  it  proceeds 
from  a  large  artery,  nothing  but  fecuring  it  with  a  lig- 
ature can  be  depended  on.  This  being  done  the 
dreffings  mull  be  renewed  in  the  fame  manner  as  at 
firft. 

The  only  other  fymptoms  that  we  have  reafon  to 
dread,  during  the  firll  three  or  four  days  after  the  ope- 
ration, are  fevere  fpafmodic  affections  of  the  mufcles, 
and  inflammation  and  tenfion  of  the  flump,  with  the 
confequent  f:iver  which  in  fome  degree  fucceeds  to 
every  cafe  of  amputation,  but  which  always  proves 
hazardous  when  it  proceds  to  a  great  height. 

When  the  arteries  are  tied  without  including  the 
nerves  or  any  part  of  the  contiguous  mufcles,  thefe 
fpafms  feldom  become  troublefome :  but  when  they 
take  place,  if  laying  the  limb  in  an  eafy  relaxed  (rate 
does  not  render  them  moderate,  we  trull  chiefly  to 
opiates  for  their  removal. 


Sea.  IV.  the  Thigh.  481 

With  a  view  to  prevent  inflammation,  the  patient 
fliould  be  confined  to  as  low  a  regimen  as  the  Itate  of 
his  ftrength  will  permit.  In  weak  emaciated  habits, 
this  mult  be  managed  with  much  difcretion,  as  the 
conftitution  might  be  materially  hurt  by  a  low  diet : 
but  where  there  is  much  plethora,  with  tenfe  fibres, 
together  with  a  ftria  antiphlogiftic  regimen,  the  pa- 
tient fhould  be  blooded  as  foon  as  quicknefs  and  ful- 
nefs  of  pulfe  or  other  fymptoms  of  fever  take  place : 
he  fhould  take  plentifully  of  diluent  drink ;  and  his 
bowels  fliould  be  kept  open  with  any  of  the  cooling 
neutral  falts. 

It  is  proper,  however,  to  obferve,  that  it  is  only  dur- 
ing the  firft  days  after  the  operation  that  remedies  of 
this  kind  are  in  general  neceifary.  When  the  inflam- 
matory fliage  is  over,  evacuations  of  every  kind  are  to 
be  dreaded ;  even  laxatives  are  apt  to  do  harm  if  car- 
ried farther  than  is  jufl  neceflary  for  preferving  a  re- 
gular fl:ate  of  the  bowels. 

At  the  end  of  the  fecond  day,  whatever  the  previ- 
ous fymptoms  may  have  been,  the  fl:ump  fliould  be 
examined.  Where  a  free  fuppuration  is  expected,  as 
always  happens  when  the  flump  is  not  covered  with 
Ikin,  the  parts  fhould  not  be  looked  at  till  the  third  or 
fourth  day  :  but  here  there  is  no  rcafon  for  this  delay  j 
and  the  patient  is  always  made  more  eafy  and  com- 
fortable by  the  removal  of  the  firfl:  dreflings.  For  this 
purpofe,  the  ftump  fhould  be  gently  fupported  by  an 
afllitant,  till  the  laft  turns  of  the  roller  are  undone, 
and  till  the  crofs  flips,  tow,  and  even  the  large  pled- 
get of  ointment  next  the  fore,  are  removed.  In  a  few 
cafes  the  parts  are  found  united  by  the  firfl  intention ; 
but  for  the  mofl  part  it  is  otherwife :  there  is  com- 
monly a  fmall  quantity  of  matter  over  the  furface  of 
the  flump,  chiefly  at  the  inferior  angle  of  the  wound  ; 
and  the  parts  are  red,  tenfe,  and  painful  to  the  touch, 
with  a  fmall  feparation  or  opening  between  the  edges 
of  the  divided  fl^in,  notwithfl;anding  the  plafliers  enx- 

VoL.  III.  H  h 


482  Of  Amputating  Chap.  XLIV. 

ployed  to  rctam  them.  As  in  this  ftate  the  plafters  do 
no  fervice,  they  ihould  Hkewife  be  removed ;  and  it 
is  eafily  done  when  they  are  thus  moiflened  with  mat- 
ter. The  furface  of  the  flump  fliould  now  be  cover- 
ed with  a  pledget  of  the  fame  ointment  as  at  firfl ;  and 
a  culhion  of  foft  tow  being  laid  over  it,  the  crofs  flips 
of  linen  and  the  circular  roller  fliould  be  again  em- 
ployed J  but  with  no  more  prelTure  than  is  merely 
neceflary  for  fupporting  them. 

In  this  manner  the  dreflings  fliould  be  renewed  dai- 
ly ;  when,  by  the  feventh  or  eighth  day,  the  inflam- 
mation and  tenfion  will  in  general  be  fo  far  diminifli- 
ed  as  to  admit  of  the  ligatures  on  the  arteries  being 
eafily  removed ;  at  leafl:  they  may  now  be  gently  pul- 
led daily,  and  for  the  mofl:  part  they  yield  on  the  fe- 
cond  or  third  trial :  when  allowed  to  remain  longer, 
they  not  only  prevent  the  wound  from  healing,  but 
are  apt  to  be  more  difficult  to  remove  afterwards. 

As  long  as  the  roller  is  prefer ved  clean,  it  may  be 
allowed  to  remain ;  but  as  foon  as  it  becomes  fuUied 
with  matter,  it  fliould  be  removed  and  another  applied 
in  its  place  j  nor  fliould  it  be  entirely  laid  afide  till  the 
third  or  fourth  week  from  the  operation.  After  this 
period,  however,  it  fliould  be  removed,  as  when  lon- 
ger continued  it  renders  the  limb  fmaller  than  the 
other. 

As  foon  as  the  fore  is  obferved  to  be  perfeflly  clean, 
with  granulations  fprouting  in  different  parts  of  it,  as 
the  pain  and  tenfion  will  now  be  quite  removed,  we 
may  with  fafety  venture  to  complete  the  cure,  by 
drawing  the  edges  of  the  wound  together  with  adhe- 
five  plaft:ers.  In  this  fl:ate  of  the  fore  no  harm  ever 
enfues  from  it,  and  it  fliortens  the  cure  confiderably. 

By  this  management,  even  the  largefl:  fl:umps  will 
for  the  mofl:  part  be  healed  in  three  or  four  weeks  ; 
often  in  lefs.  But  it  mufl;  be  remarked^  that  although 
we  may  in  general  depend  on  this  in  private  praftice, 
where  every  circumftance  that  can  conduce  to  the 
welfare  of  the  patient  will  meet  with  attention,  and 


Sea.  IV.  ihe  TJjigIn  483 

where  efpecially  we  may  always  obtain  a  well  venti- 
lated apartment  and  proper  diet ;  yet  in  public  hofpit- 
als,  where  thefe  points  are  not  duly  attended  to,  and 
where  the  patient  often  fuffers  more  from  the  bad  air 
that  he  breathes,  than  from  the  operation  itfelf,  our 
fuccefs  will  not  in  every  cafe  be  fo  great.  Inftead  of 
the  teguments  adhering  to  the  parts  beneath,  large 
quantities  of  matter  fometimes  form  between  them, 
which  always  renders  the  cure  more  tedious,  and 
which  in  fome  cafes  cannot  be  accomplifhed  but  by 
fending  the  patient  to  a  .more  free  air,  and  by  a  more 
plentiful  allowance  of  wine  and  other  cordials  than 
can  in  general  be  obtained  in  hofpitals.  But  for  one 
inftance  of  this,  in  the  operation  that  I  have  defcribed, 
I  may  with  fafety  affirm,  that  twenty  occur  in  the 
ufual  mode  of  conducting  it. 

When  fpeaking  of  the  time  In  which  (lumps  may 
be  expeded  to  heal,  I  think  it  right  to  obferve,  that  it 
fhould  not  be  our  objed:  to  heal  the  parts  in  the  firft 
inflance  without  the  formation  of  matter  :  it  common- 
ly anfvvers  better  when  done  in  the  more  gradual  man- 
ner I  have  pointed  out.  When  a  ftump  heals  fudden- 
ly,  and  the  edges  of  the  divided  (kin  adhere  by  the 
firft  intention,  the  teguments  are  apt  to  be  puckered 
and  uneven,  and  the  ligatures  of  the  arteries  are  re- 
moved with  difficulty.  Of  this  I  have  had  difierent 
cafes,  when  fuch  ftrong  adhefive  plafters  were  em- 
ployed, as  kept  the  edges  of  the  (kin  in  clofe  contact : 
but  when  the  common  court  plafter  is  made  ufe  of, 
or  any  other  compofition  poffiilTed  of  the  fame  degree 
of  adhefive  property,  although  the  teguments  will  be 
prevented  from  feparating  to  any  confiderable  extent, 
yet  they  will  readily  yield  to  the  retraftion  that  ufual- 
ly  takes  place  on  the  acceffion  of  tenfion  and  pain. 
In  this  manner,  a  (light  feparation  is  ufual ly  produc- 
ed ;  by  means  of  which  the  ligatures  are  eafily  taken 
out ;  any  matter  that  may  form  is  readily  difcharged  ; 
the  corners  left  above  and  beneath  by  the  teguments 
H  li  2 


434  Of  Amputating  Chap.  XLIV. 

being  drawn  together,  are  much  leffened ;  and  the 
ftump  is  always  left  fmooth  and  eqiial :  hence  thofe 
flumps  which  take  three  weeks  or  perhaps  a  month 
to  heal,  are  ufually  of  a  better  form  than  thofe  that 
heal  much  fooner. 

The  advantages  attending  a  fpeedy  cure,  and  cov- 
ering the  ftump  with  fkin,  are  fo  great,  that  they  need 
not  be  enumerated ;  but  I  thought  it  right  to  men- 
tion the  inconveniencies  that  occur  from  the  union  of 
the  divided  (kin  being  too  quickly  connected,  either 
with  adhefive  plaflers,  or  futures,  which  lafl  have  In 
Ibme  cafes  been  employed. 

It  will  be  readily  perceived,  that  the  principal  dif- 
ference between  this  operation  and  the  ufual  method 
of  amputating,  confifts  in  the  faving  as  much  of  the 
mufcular  fubllance  of  the  limb  as  will  completely 
cover  the  bone,  together  with  as  much  fkin  as  will 
cover  the  whole  furface  of  the  ftump  :  but  it  is  pro- 
per to  remark,  that  we  may  err  in  faving  more  of  each 
of  thefe  parts  than  is  requifite,  and  that  fome  atten- 
tion is  therefore  necelTary  to  guard  againfl  it.  In  leav- 
ing too  much  mufcular  fubftance,  we  muft  neceflarily 
Ihorten  the  limb  too  much,  by  fawing  the  bone  higher 
than  we  otherwife  would  do  j  and  by  faving  too  much 
fkin,  we  render  the  furface  of  tlie  ftump  puckered 
and  uneven. 

With  refped  to  the  quantity  of  mufcular  fubftance 
that  ftiould  be  faved,  I  have  hitherto  found,  that  the 
direftions  given  above,  in  general  anfwer  the  purpofe. 
By  feparating  the  mufcles  from  the  bone  for  the  fpace 
of  an  inch,  and  fawing  it  at  this  height  above  where 
it  is  divided  in  the  ordinary  method  of  amputating, 
the  bone  will  always  be  fufficiently  covered  with  iiefh; 
and  a  very  little  experience  enables  us  to  judge  of  the 
quantity  of  lldn  that  fliould  be  faved  for  covering  the 
ftump :  but  even  when  more  is  faved  than  is  neccfla- 
ry  for  this  purpofe,  a  little  attention  will  enable  us  to 
prevent  inequalities.  By  an  aftiftant  drawing  down 
the  teguments,  in  the  manner  I  haVe  direfted,  before 


Sea.  IV.  the  Thigh,  485 

the  roller  is  applied,  as  much  of  them  may  be  pulled 
down  as  is  juft  neceffary  ;  and  if  they  are  kept  in  this 
fituation  till  the  application  of  the  roller  is  finiflied, 
any  inconveniency  which  might  have  enfued  from  too 
great  a  quantity  will  be  prevented. 

It  will  likewife  be  obferved,  that  in  making  the  firfl: 
incifion  of  the  teguments,  I  have  not  defired  a  circu- 
lar piece  of  tape  to  be  made  ufe  of,  as  is  ufually  done, 
to  ferve  as  a  direction  for  the  knife.  This  deviation 
from  the  common  pra£lice  has  been  long  adopted  by 
fome  individuals ;  but  fo  far  as  I  know,  it  was  firfl 
fuggefted  by  the  late  Dr.  Hunter  of  London ;  and  I 
think  it  a  material  improvement  of  this  part  of  the 
operation :  for  bcfides  the  faving  of  time,  which  is 
always  of  importance  in  that  ftate  of  anxiety  to  which 
a  patient  is  reduced  who  is  placed  upon  a  table  for  the 
purpofe  of  lofmg  a  limb,  it  in  reality  puts  it  in  our 
power  to  make  the  incifion  with  more  neatnefs,  more 
fpeedily,  and  with  lefs  embarraffment,  than  when  the 
tape  is  employed.  Thofe  who  have  been  accuftomed 
to  ufe  the  tape  will  at  iirft  be  of  a  different  opinion  ; 
but  whoever  lays  it  afide,  will  fmd,  that  the  circular 
incifion  may  be  made  with  more  exaftnefs  merely  by 
following  the  knife  with  the  eye  ;  and  I  am  certain 
that  it  may  be  done  in  one  half  of  the  time.  When 
the  tape  is  employed  a  good  deal  of  time  is  loft  in  en- 
deavouring to  keep  the  knife  exactly  in  a  line  with 
the  edge  of  it ;  and  if  not  applied  with  the  utmoft  ex- 
aftnefs,  it  neceffarily  makes  the  incifion  ragged  and 
unequal ;  an  occurrence  I  have  obferved  in  different 
inftances,  even  with  expert  furgeons,  while  I  never 
perceived  any  inequality  where  the  tape  was  not  made 
ufe  of. 

It  has  been  obje6led  to  the  operation  that  I  have 
defcribed,  that  being  more  tedious  than  the  ufual  me- 
thod of  amputating,  it  muft  neceffarily  create  more 
pain.  The  difference  in  this  refpeft,  however,  is  tri- 
fling ;  for  it  muft  be  remembered,  that  the  incifion 
of  the  fkin,  and  this  is  the  moft  painful  part  in  every . 


486  Of  Amputating  Chap.  XLIV- 

operatloR,  is  the  fame  in  both.  The  divifion  of  the 
cellular  fubflance  is  quickly  performed,  and  little  or 
no  pain  enfues  from  it  ;  and  the  third  incifion,  if  we 
may  fo  term  it,  or  the  feparation  of  the  mufcles  from 
the  bone,  may  be  performed  in  the  tenth  part  of  a 
minute.  In  different  inftances,  I  made  ufe  of  a  fcaU 
pel  for  feparating  the  cellular  fubftance  from  the  muf- 
cles beneath,  as  well  as  for  feparating  the  mufcles  from 
the  bone  ;  but  I  now  find  that  both  thefe  parts  of  the 
operation  may  be  done  with  the  common  amputating 
knife,  with  equal  eafe  and  expedition  ;  and  we  fhould 
avoid  multiplying  inftruments,  wherever  the  intention 
can  be  anfwered  equally  well  with  a  fmaller  number. 
The  knife  delineated  in  Plate  XCVIII.  fig.  3.  is  the 
one  I  now  prefer,  after  trying  various  forms  of  it  :  it 
is  of  a  middling  fize,  fomewhat  fliorter  than  the  one 
in  common  ufe,  and  perfedly  flraight.  The  curved 
knife  is  ftill  ufed  by  fome  praQitioners,  but  no  good 
reafon  has  been  afngned  for  it. 

If  any  furgeon  fhould  find  it  difficult  to  feparate  the 
mufcles  from  the  bone  with  this  knife,  the  inftrument 
recommended  by  Mr.  Gooch,  and  delineated  in  Plate 
XCVIII.  fig.  4.  may  be  employed. 

I  Ihall  now  defcribe  fuch  parts  of  Mr.  Alanfon's 
method  of  performing  this  operation  as  are  peculiar 
to  himfelf ;  and  in  order  to  convey  the  meaning  of 
the  author  with  exaftnefs,  I  fnall  give  it  in  his  own 
words,  from  the  fecond  and  lafl  edition  of  his  book, 
page  51. 

*'  Apply  the  tourniquet  in  the  ufual  way  ;  ftand  on 
the  outfide  of  the  thigh  ;  and  let  an  affiflant  draw  up 
the  (kin  and  mufcles,  by  firmly  grafping  the  limb  cir- 
cularly with  both  hands.  The  operator  then  makes 
the  circular  incifion  as  quickly  as  poffible  through  the 
fkin  and  membrana  adipofa  down  to  the  mufcles  :  he 
next  feparates  the  cellular  and  membranous  attach- 
ments with  the  edge  of  his  knife,  till  as  much  fkin  is 
drawn  back  as  will  afterwards,  conjointly  with  the 


Sea.  IV.  the  T/jigb.  487 

following  divifion  of  the  mufcles,  cover  the  furface  of 
the  wound  with  the  mod  perfect  eafe. 

"  The  affiftant  flill  firmly  fupporting  the  parts  as  be- 
fore, apply  the  edge  of  your  knife  upon  the  inner  edge 
of  the  mufculous  vaftus  ifiternus,  and  at  one  flroke  cut 
obliquely  through  the  mufcles  upwards  as  to  the  limb 
and  down  to  the  bone  ;  or  in  other  words,  cut  in  fuch 
a  direction  as  to  lay  the  bone  bare  about  two  or  three 
fingers  breadth  higher  than  is  ufually  done  by  the  com- 
mon perpendicular  circular  incifion  :  now  draw  the 
knife  towards  you,  fo  that  its  point  may  reft:  upon  the 
bone,  ftiill  attending  to  keep  it  in  the  fame  oblique  line, 
that  the  mufcles  may  be  divided  all  round  the  limb  in 
that  direction  by  a  proper  turn  of  the  knife ;  during 
which  its  point  is  kept  in  contact  with,  and  revolves 
round,  the  bone. 

"  The  part  where  the  bone  is  to  be  laid  bare,  whe- 
ther two,  three,  or  four  fingers  breadth  higher  than  the 
edge  of  the  retracted  integuments  ;  or,  in  other  words, 
the  quantity  of  mufcular  fubft:ance  to  be  taken  out  in 
making  the  double  incifion,  muft;  be  regulated  by  con- 
fidering  the  length  of  the  limb,  and  the  quantity  of  fkin 
that  has  been  previoufly  faveu  by  dividing  the  membra- 
nous attachments. 

"  The  quantity  of  fkin  faved,  and  mufcular  fubfl:ance 
taken  out,  muft:  be  in  fuch  an  exact  proportion  to  each 
other,  as  that,  by  a  removal  of  both,  the  whole  furface 
of  the  wound  will  afterwards  be  eafily  covered,  and 
the  length  of  the  limb  not  more  fliortened  than  is  ne- 
ceflary  to  obtain  this  end.  However,  it  is  to  be  obfer- 
ved,  that  the  more  mufcular  fubftance  we  fave,  by  ful- 
ly giving  the  oblique  direction  to  the  knife,  inft:ead  of 
dividing  the  membranous  attachments,  the  better." 

Mr.  Alanfon  now  gives  fome  directions  for  the  ufe 
of  the  retractor  ;  for  fecuring  the  divided  arteries  with 
ligatures  ;  and  for  the  application  of  the  flannel  roller. 
Afterwards  he  proceeds  thus :  "  You  are  now  to  place 
the  ikin  and  mufcles  over  the  bone  in  fuch  a  direftion 
as  that  the  wound  fliall  appear  only  in  a  line  with  the 


483  Of  Amputating  Chap.  XLIV. 

angles  at  each  Tide ;  from  which  pohits  the  ligatures 
are  to  be  left  out,  as  their  vicinity  to  either  angle  di- 
rects :  the  Ikin  is  eafily  fecured  in  this  pofture  by  long 
flips  of  linen  or  lint,  about  two  fingers  in  breadth, 
fpread  with  cerate  or  any  other  ointment :  if  the  fkia 
do  not  eafily  meet,  it  is  bed  brought  into  contadt  by 
flips  of  linen  fpread  with  fliicking  plaft:er.  Thefe  are 
to  be  applied  from  below  upwards  acrofs  the  face  of 
the  flump,  and  over  thern  a  foft  tovv  pledget  and  com- 
prefs  of  linen,  the  whole  to  be  retained  by  the  many 
tailed  bandage,  with  two  tails  or  flips  to  come  from 
below  upwards,  to  retain  the  dreflings  upon  the  face 
of  the  flump.'* 

Mr.  Alanfon  ufes  a  knife  with  a  double  edge,  which 
he  thinks  preferable  to  the  one  commonly  employed. 

As  I  wifli  the  author's  ideas  to  be  clearly  under- 
flood  I  think  it  right  to  add,  that  in  p.  17,  he  directs 
the  bone  to  be  laid  bare  three  or  four  fingers  breadth 
higher  than  is  ufually  done  by  the  common  perpen- 
dicular incifion  of  the  mufcles ;  that  is,  that  by  the 
oblique  direction  of  the  knife,  three  or  four  «fmgers 
breadth  of  mufcular  fubilance  fbould  be  fcooped  out. 
And,  in  page  21,  he  obferves,  "  that  a  flump  formed 
in  the  thigh,  agreeably  to  the  foregoing  plan,  if  you 
bring  the  parts  gently  forwards  after  the  operation, 
and  then  view  the  furface  of  the  wound,  may,  in  fome 
degree,  be  faid  to  refemble  a  conical  cavity,  the  apex 
of  which  is  the  extremity  of  the  bone  ;"  and  the  parts 
thus  divided,  he  obferves  are  obvioufly  the  befl  cal- 
culated to  prevent  a  fugar-loaf  flump.- 

From  what  has  been  faid,  it  will  appear,  that  Mr. 
Alanfon's  method  of  operating  differs  chiefly  from 
that  which  I  have  advifed  above,  in  the  manner  of  di- 
viding the  rnufcles,  and  in  the  after  pofition  of  the 
fkin.  Every  furgeon  is  apt  to  be  partial  to  that  mode 
of  operating  which  he  has  been  accuflomed  to  prac- 
tife  J  but  being  ahvays  anxious  to  have  this  very  im- 
portant operation  improved  to  the  highefl  pofTible  de- 
gree, I  was  refolved  to  give  Mr.  Alanfon's  method  a 


Sea.  IV.  fhe  Thigh.  489 

fair  trial,  being  hopeful,  from  the  accounts  received  of 
it,  that  I  fhould  find  it  anfwer  better  even  than  that 
of  which  I  have  fpoken  fo  highly.  I  can  with  truth, 
however,  affert,  that  it  did  not  anfwer  my  expedation. 
The  Itumps  formed  by  it  are,  indeed,  much  better 
than  can  be  made  by  the  ufual  method  of  amputating  ; 
but  the  removal  of  fuch  a  large  portion  of  mufcular 
fubftance,  as  is  done  by  Mr.  Alanfon's  oblique  inci- 
fion,  produces  a  hollow,  that  not  only  retains  the  mat- 
ter, but  prevents  the  ftump  from  being  fo  fmooth  and 
equal  as  when  the  fkin  is  fupported  by  a  flat  mufcular 
furface  in  the  manner  I  have  advifed.  Mr.  Alanfon, 
who  is  in  the  daily  pradice  of  it,  may  be  able  to  ob- 
viate thefe  difficulties ;  but  I  know  that  I  cannot  make 
fuch  a  good  flump  in  this  manner  as  I  always  do  in 
the  other  method  of  operating  ;  nor  is  Mr.  Alanfon's 
own  idea  fo  completely  anfwered  by  his  method  of 
operating.  He  very  properly  obferves,  page  36,  that 
in  the  thigh  we  want  a  fufficient  cufliion  between  the 
bone  and  machine  to  be  ufed  in  walking ;  that  the 
more  mufcular  fubflance  that  is  faved,  the  farther  will 
the  point  of  bone  on  which  the  preffure  principally 
produces  inconvenience,  be  removed  from  the  furface 
of  the  machine ;  and  likewife,  that  a  more  vigorous 
circulation  will  be  kept  up  all  round  the  extremity  of 
the  bone  and  flump,  which  lefTens  the  danger  of  ex- 
foliation. Now,  it  is  obvious,  that  the  end  of  the 
bone  will  not  be  fo  much  covered  with  mufcular  fub- 
ftance when  a  confiderable  portion  of  the  mufcles  is 
removed  by  the  oblique  incifion  as  w^hen  they  are  al- 
lowed to  remain  ;  nor  will  the  circulation  be  fo  vigor- 
ous round  the  end  of  the  bone. 

But  admitting  Mr.  Alanfon's  method  of  operating 
to  be  in  every  point  equal  to  the  other,  the  greater 
difficulty  of  performing  it  is  a  weighty  objedion  againfl 
it.  Indeed  few,  I  believe,  will  be  able  to  divide  the 
mufcles  by  the  oblique  incifion  without  mangling  the 
fkin,  even  with  the  explanation  given  by  Mr.  Alanfon 
in  the  lafl  edition  of  his  book.     Accordingly  we  find, 


49^  Of  Amputatmg  Chap.  XLIV. 

in  page  204,  that  this  actually  happened  in  the  hands 
of  an  expert  furgeon,  Mr.  Lucas  of  Leeds,  even  where 
the  divifion  of  the  mufcles  was  not  begun  clofe  under 
the  retracted  integuments,  but  a  little  lower.  Nor 
will  this  be  an  uncommon  occurrence,  if  the  mufcles 
are  divided  with  the  edge  of  the  knife,  as  is  directed 
by  Mr.  Alanfon.  I  have  divided  them  with  the  point 
of  the  knife,  but  with  dilFiciilty  ;  for  the  point  cannot 
be  eafily  carried  round  to  the  height  of  three  or  four 
fingers  breadth  above  the  retracled  fkin,  fo  as  to  make 
a  fmooth  equal  cut.  I  do  not  fee  how  the  edge  of  the 
knife  can  be  applied  to  cut  fo  obliquely  upwards  with- 
out hurting  the  Ikin ;  and  yet  Mr.  Alanfon's  words 
are,  "  apply  the  edge  of  your  knife,  and  at  one  ftroke 
cut  obliquely  through  the  mufcles,"  he.  He  defires, 
indeed,  that  the  incifion  may  be  finiflied  with  the  point ; 
but  I  do  not  underftand  how  it  can  be  done  without 
cutting  the  fkin,  if  the  point  be  not  employed  from 
firfl  to  laft  in  the  divifion  of  the  mufcles.  Indeed, 
Mr.  Alanfon  himfelf  admits  that  there  is  difficulty  in 
this  part  of  the  operation  ;  for  in  page  1 8,  he  fays, 
"  that,  while  one  afTiflant  continues  a  firm  and  Heady 
elevation  of  the  parts,  another  fhould  attend  to  prefers'e 
the  fkin  from  being  wounded  as  the  knife  goes  through 
the  mufcles  at  the  under  part  of  the  limb."  This,  of 
itfelf,  appears  to  be  a  material  objeftion  to  this  method 
of  operating  :  for  two  alliflants,  whofe  hands  are  all 
employed  nearly  at  one  point,  muft  be  apt  to  embar- 
rafs  not  only  each  other  but  the  operator  :  and  befides, 
it  muit  often  happen,  that  two  afliftants  cannot  be  pro- 
cured. 

With  refpecl  to  the  line  of  direction  in  which  the 
wound  fliould  be  clofed,  Mr.  Alanfon  obferves,  page 
^^j^  if  it  be  formed  from  above  downwards,  the  cica- 
trix will  generally  be  found  dire6lly  oppofite  to  the 
bone  ;  by  which,  in  walking  with  an  artificial  leg,  the 
point  of  preffure  muft  be  upon  the  new  formed  fkin ; 
which  he  thinks  will  be  avoided  by  forming  the  line 
in  the  contrary  -direction  from  fide  to  fide  :  in  which 


Sea.  IV.  the  Thigh,  491 

cafe,  after  the  cure  is  complete,  it  will  be  found,  that 
in  confequence  of  the  more  powerful  aftion  of  the  flex- 
or mufcles,  the  cicatrix  is  drawn  downwards,  and  the 
extremity  of  the  bone  is  therefore  covered  with  the  old 
fkin  ;  by  which  the  greateft  preflure  falls  upon  this 
part,  and  not  upon  the  new  formed  fkin. 

I  have  not  found,  however,  that  this  argument  is 
of  much  importance  ;  for  this  retraction  of  the  flexor 
mufcles  to  which  Mr.  Aknfon  alludes,  is  in  a  great 
meafure  owing  to  the  cufl:om  of  elevating  the  fl:ump 
after  the  operation,  and  may  be  prevented  by  keeping 
it  lower  than  the  refl:  of  the  body,  in  the  manner  I 
have  mentioned.  And  befides,  the  bone  is  fo  well 
covered  with  mufcular  fubftance,  and  the  cicatrix  fo 
narrow  when  the  operation  is  rightly  done,  that  I  have 
not  met  with  a  fmgle  infliance  of  any  inconvenience 
arifmg  from  this  circumfl:ance  mentioned  by  Mr.  Al- 
anfon  :  whereas,  the  lodgment  of  matter  proves  always 
fo  troublefome  and  pernicious,  and  would  in  all  pro- 
bability occur  fo  frequently,  were  the  praftice  gener- 
ally adopted  of  making  a  tranfverfe  opening  inftead  of 
a  longitudinal  one  upon  the  face  of  the  flump,  that 
this  appears  to  be  a  fuflicient  reafon  for  preferring  the 
former. 

With  a  view  to  prevent  that  inequality  on  the  fur- 
face  of  the  flump,  which  arifes  from  the  retraction  of 
the  flexor  mufcles  of  the  thigh,  I  have  in  fome  cafes 
divided  thefe  mufcles  an  inch  lower  than  thofe  of  the 
refl  of  the  limb.  After  dividing  the  fkin  and  cellular 
fubflance  with  a  circular  incifion  in  the  ufual  way,  this 
is  eafily  done ;  and  it  prevents  this  inconvenience  in 
the  moft  effeftual  manner  :  but  it  is  not  necefTary  when 
the  flump  is  treated  in  the  manner  I  have  mentioned. 

Whether  others  may  deem  thefe  obfervations  upon 
Mr.  Alanfon's  method  of  amputating  important  or 
not,  I  cannot  determine  ;  but  as  they  appeared  to  me 
to  be  of  confequence,  I  thought  it  my  duty  to  offer 
them. 


49*  Of  Amputating  Chap.  XLIV. 

It  is  but  juftice,  however,  to  remark,  that  the  pub- 
lic is  much  indebted  to  INIr.  Alanfon  for  his  afliduity 
in  endeavouring  to  improve  this  very  important  oper- 
ation, and  for  the  many  ufeful  pradical  remarks  con- 
tained in  his  pubhcation. 


SECTION    V. 
Of  Amputating  the  Leg, 


IN  amputating  the  thigh  I  have  obferved,  that  ag 
much  of  the  hmb  fhould  be  faved  as  can  be  done 
with  fafety  ;  for  the  longer  the  Itump  the  more  utility 
is  derived  from  it :  but  in  amputating  the  leg,  it  has 
hitherto  been  a  general  rule  to  take  it  off  a  little  below 
the  knee,  even  where  the  difeafe  is  feated  on  or  near 
to  the  ankle,  and  where  accordingly  the  operation 
might  be  performed  much  lower.  The  reafon  given 
for  this  is,  that  a  few  inches  of  the  leg  being  faved, 
anfwers  as  a  fufficient  reft  to  the  body  in  walking  when 
the  limb  is  inferted  into  the  box  of  a  wooden  leg  ;  and 
when  much  more  of  it  is  left,  that  it  proves  trouble- 
fome  both  in  walking  and  fitting,  without  being  at- 
tended with  any  particular  advantage. 

AVere  we  to  conclude,  that  the  common  p^a6i:ice  of 
bending  the  joint  of  the  knee  and  refting  upon  the  an- 
terior part  of  the  leg  was  necefi'ary,  this  method  of 
operating  a  little  below  the  knee  would  be  admitted 
as  the  beft  :  but  as  we  have  now  had  many  inftances 
of  patients  walking  equally  well  with  machines,  fo 
contrived  as  to  admit  of  the  ufe  of  the  knee  joint ;  as 
thefe  machines,  by  refembling  the  human  leg,  are 
much  more  pleafmg  to  the  eye  than  the  wooden  ones 
in  common  ufe ;  and  as  the  operation  may  be  done 
with  much  more  eafe  and  fafety  to  the  patient  a  little 
above  the  ankle,  I  am  of  opinion  that  it  fliould  always 


Seel.  V.  ihe  Leg,  493 

be  done  here  whenever  It  is  practicable,  Indead  of  the 
ordinary  place  a  little  below  the  knee. 

The  operation  is  eafier  performed  a  little  above  the 
ankle  than  at  the  upper  part  of  the  leg,  by  the  parts 
to  be  divided  being  lefs  extenftve  j  for  the  diameter 
of  the  \e.g  is  here  confidcrably  Icfs  ;  and  it  is  done  with 
more  fafety  by  our  being  able  to  cover  the  bone  more 
completely  with  foft  parts,  fo  as  to  accomplifli  a  cure 
m  the  fame  manner  and  equally  foon  as  in  the  thigh : 
whereas,  immediately  below  the  knee,  the  bones  are 
not  only  larger,  but  there  is  fuch  a  fcarcity  of  foft 
parts,  that  the  cure  proves  always  much  more  tedious, 
notwithftanding  all  our  endeavours  to  promote  it  ;  in- 
fomuch,  that  in  operating  at  the  ufual  place,  about 
four  inches  beneath  the  patella,  the  fore,  with  all  the 
attention  we  can  give  to  it,  will  feldom  heal  in  lefs  than 
ten  or  twelve  weeks  ;  and  in  the  common  method  of 
forming  the  double  incifion,  it  will  even  require  four 
or  five  months :  whereas,  when  the  operation  is  right- 
ly performed  a  fev/  inches  above  the  ankle,  a  cure 
may,  for  the  moll  part,  be  effeCled  in  a  fortnight  or 
three  weeks. 

It  is  true  that  a  method  of  amputating  beneath  the 
knee  has  been  propofed,  by  what  is  termed  the  flap 
operation,  and  by  which  a  cure  may  be  more  fpeedily 
obtained  than  in  the  ufual  way  of  operating  ;  but  (till 
it  is  tedious,  and  at  the  fame  time  liable  to  other  ob* 
jeftions,  which  I  fhall  have  prefently  occafionto  men- 
tion. I  therefore  conclude,  that  in  every  cafe  that  ad- 
mits of  it,  amputating  a  little  above  the  ankle  is  pre- 
ferable to  operating  immediately  below  the  knee. 

We  are  next  to  determine  the  mod  proper  place 
for  the  operation,  when  we  are  prevented  by  the  extent 
of  the  difea^c  in  the  leg  from  amputating  lower  than 
the  ufual  place  beneath  the  knee.  Where  the  upper 
part  of  the  leg  is  found,  it  has  hitherto  been  a  fixed 
maxim  to  amputate  below  the  joint  of  the  knee  rather 
than  above  it. 


494  Of  Amputating  Chap.  XLIV^ 

While  pra£lItioners  were  unacquainted  with  the 
prefent  improvements  on  this  operation,  they  feem  to 
have  adopted  this  maxim,  chiefly  from  finding  that 
the  body  refled  more  eafily  upon  the  found  Ikin  on 
the  forepart  of  the  leg  than  on  the  (lump  of  the  thigh  : 
but  now  that  the  operation,  when  done  above  the  knee^ 
may  be  fo  performed  that  the  fore  will  heal  in  lefs  than 
one  half  of  the  time  that  is  required  when  the  leg  is 
taken  off  immediately  below  the  joint ;  and  in  fuch  a 
manner  that  the  flump  is  covered  with  found  fkin,  as 
well  as  with  fome  mufcular  fubftance,  which  admits 
of  the  patient  refling  upon  it  with  freedom  ;  this  rea- 
fon,  upon  which  the  practice  is  chiefly  founded,  falls 
to  the  ground. 

I  have  obferved  above,  that  the  cure  of  a  flump  im- 
mediately below  the  knee  is  always  tedious,  owing  to 
the  great  extent  of  bone  at  this  place,  and  the  natural 
deficiency  of  foft  parts. 

Upon  the  whole,  therefore,  I  conclude,  that  ampu- 
tation immediately  below  the  knee  fliould  feldom  or 
never  be  advifed  :  but  as  no  innovation  will  at  firfl  be 
generally  admitted,  I  think  it  right  to  defcribe  the 
method  of  operating  when  it  is  determined  to  ampu- 
tate at  this  part. 

The  patient  fhould  be  placed  upon  a  table  and  fe- 
cured  in  the  fame  manner  as  in  operating  above  the 
knee.  The  tourniquet  fhould  be  applied  a  little  above 
the  knee,  with  the  cufliion  upon  the  artery  in  the  ham. 
The  foot  and  leg  fhould  be  fecured  by  an  affiflant  fit- 
ting before  the  patient,  while  the  teguments  are  drawn 
up  by  another  affiflant  towards  the  knee.  The  fur- 
geon,  flanding  on  the  infide  of  the  leg,  fliould  now 
with  the  knife,  Plate  XCVIII.  fig.  3.  make  a  circular 
cut  through  the  fldn  and  cellular  fubflance  down  to 
the  mufclcs,  fo  far  down  upon  the  limb,  that  when  as 
much  of  the  teguments  are  feparated  from  the  parts 
beneath  as  will  cover  the  ftump,  the  muFcles  and  bones 
may  be  divided  immediately  below  the  infertion  of  the 
flexor  tendons  of  the  leg.     The  intcroffeous  foft  parts 


Se£t.  V.  the  Leg,  495 

mufl:  be  divided  either  with  the  point  of  the  amputa- 
ting knife  or  with  the  catline,  Plate  XCVIII.  fig.  2. 
The  retradors,  Plate  XCVIT.  fig.  2.  and  3.  mufl:  now 
be  applied  fo  as  to  fupport  and  protect  the  fkin  and 
other  foft  parts  from  the  faw  employed  ior  dividing 
the  bones.  This  being  done,  and  the  vefTels  fecured 
in  the  ufual  way  with  ligatures,  the  teguments  fhould 
be  drawn  over  the  ftump  and  retained  with  adhefive 
plafliers,  in  the  manner  I  have  advifed  in  amputating 
the  thigh.  The  practice,  indeed,  fliould  be  the  fame 
during  the  whole  courfe  of  the  cure  ;  only,  in  the  ap- 
plication of  the  flannel  roller,  there  is  no  neceffity  for 
beginning  at  the  top  of  the  thigh  :  it  fliould  receive, 
however,  two  or  three  turns  above  the  knee,  to  pre- 
vent it  from  flipping  down. 

In  feparating  the  adhcfions  of  the  fkin  from  the  parts 
beneath,  as  much  of  the  cellular  fubflance  fhould  be 
taken  along  with  it  as  can  be  got ;  otherwife  the  cir- 
culation in  the  fkin  itfelf  is  apt  to  become  fo  languid 
as  to  prevent  it  from  adhering  to  the  parts  on  which 
it  is  applied.  It  will  be  found  too,  that  more  attention 
is  necelfary  to  deflroy  the  attachments  of  the  fkin  in 
this  fituation,  particularly  on  the  forepart  of  the  leg, 
than  in  the  thigh,  owing  to  the  cellular  fubflance  be- 
ing more  condenfed  where  it  lies  fo  contiguous  to  the 
bone,  than  in  the  thigh,  where  the  mufcles  intervene. 
And  as  this  flate  of  the  cellular  membrane  prevents 
the  teguments  from  retracing  freely  after  they  are  di- 
vided ;  and  as  they  cannot  even  be  pulled  fufficiently 
up  by  the  afliftant,  it  is  neceffary  to  fold  fuch  of  them 
as  are  feparated  from  the  parts  beneath,  back  upon  the 
found  fkin,  before  the  divifion  of  the  mufcles  is  at- 
tempted ;  otherwife  the  fl^in  will  either  be  cut  with  a 
knife,  or  the  mufcles  will  not  be  divided  fo  high  as 
they  ought  to  be. 

Always  at  this  part  of  the  leg,  and  in  a  few  cafes 
immediately  above  the  ankle,  I  have  found  it  necefl'ary 
to  fold  the  Ikin  back  in  this  manner  ;  but  hitherto  no 
inftance  has  occurred  in  the  thigh,  vvhere  the  operation 


49^  OfJmputailng  Chap.  XLIV. 

might  not  have  been  done  merely  by  pulling  the  teg- 
uments up,  in  the  manner  I  have  formerly  mentioned. 

I  have  defired  above,  that  in  this  operation  the  fur- 
geon  ihould  ftand  on  the  infide  of  the  leg :  by  this,  if 
the  knee  and  foot  are  turned  inwards,  i'o  as  to  raife 
the  fibula,  the  faw  may  be  appUed  in  fuch  a  manner 
to  both  bones  as  to  divide  them  nearly  together,  the 
fureft  method  of  preventing  them  from  breaking  when 
nearly  fawn  through  :  whereas,  on  (landing  on  the 
outfide  of  the  patient,  the  fibula  is  more  apt  to  be  left 
to  the  laft  ;  at  the  fame  time  that  the  faw  is  apphed 
upon  the  ridge  of  the  tibia,  fo  as  to  acl  upon  its  long- 
eft  diameter,  by  which  it  is  not  fo  quickly  divided. 

In  operating  above  the  ankle,  that  fpot  fhould  be 
fixed  upon  that  will  leave  the  ftump  of  the  mofl  con- 
venient length  for  being  fitted  with  a  leather  machine 
refembling  the  other  leg.  And  I  find  from  obferva- 
tion,  as  well  as  from  information  obtained  from  Mr. 
Wilfon,  a  late  ingenious  tradefman  of  this  place,  that 
nine  inches  from  the  joint  of  the  knee  is  the  belt 
length  for  this  purpofe  ;  for  it  affords  a  fuHicient  fup- 
port  to  the  machine,  and  at  the  fame  time  prevents  it 
from  being  fo  heavy  and  clumfy  as  when  the  leg  is 
left  of  a  greater  length  :  for  when  taken  off  immedi- 
ately above  the  ankle,  the  flump  mufl  go  down  to  the 
very  bottom  of  the  machine,  which  muff  therefore  be 
thicker  and  heavier  at  the  ankle  than  it  otherwife 
might  be  ;  at  the  fame  time  that  it  will  not  correfpond 
fo  exa£lly  as  it  otherwife  would  do  to  the  fize  of  the 
other  leg. 

In  addition  to  what  I  have  faid  upon  the  method  of 
amputating  the  leg  immediately  below  the  knee,  I  may 
obferve,  that,  in  operating  above  the  ankle,  it  fhould 
be  done  exaftly  as  I  have  advifed  in  defcribing  the 
amputation  of  the  thigh  :  only  in  this  fituation,  inftead 
of  m.ufcles,  we  find  a  portion  of  both  bones  covered 
merely  wdth  fkin  and  cellular  fubftance ;  but  as  the 
cellar  membrane  is  here  commonly  fufficiently  lax, 


Se£t.  VI.  with  a  Flap;  497 

and  in  greater  quantity  than  in  the  upper  part  of  the 
leg,  it  is  not  only  more  eafily  leparated  from  tTie  peri- 
ofteum,  but  ferves  to  give  the  bones  a  more  complete 
covering :  by  which,  vi^hen  the  operation  is  properly 
done,  the  cure  for  the  moft  part  is  accomplilhed  in 
lefs  than  three  weeks,  and  the  furface  of  the  ftump  is 
equal,  and  every  where  covered  with  found  Ikin. 


SECTION     VI. 

Of  Amputating  with  a  Flap* 

IN  amputating  in  the  ufual  way,  the  cure  was  fo  ex- 
tremely tedious  ;  the  health  of  the  patient  was 
thereby  fo  much  injured  ;  and  the  flumps,  when  heal- 
ed, were  fo  pyramidal,  and  fo  thinly  covered  with  foft 
parts,  that  another  method  of  operating,  as  I  have  ob- 
ferved  above,  was  propofed  upwards  of  a  hundred 
years  ago  ;  in  which  an  attempt  was  made  to  obviate 
thefe  difficulties,  by  preferving  a  flap  of  mufcles  and 
fldn  for  the  purpofe  of  covering  the  flump. 

This  was  firfl  propofed  by  one  Loudham,  a  Britifh 
furgeon  :  it  was  afterwards  praclifed  in  Holland,  Ger- 
many, Switzerland,  and  France ;  and  more  lately  by 
fome  individuals  in  Britain  and  Ireland :  but  it  has 
never  been  received  into  general  ufe,  nor  is  it  proba- 
ble that  it  will  ever  be  frequently  performed. 

The  chief  objeftions  to  it  were,  the  difficulty  of  re- 
flraining  hemorrhagies  when  they  happened  to  recur 
after  the  flap  was  applied  and  fixed  in  its  fituation  with 
futures,  for  in  order  to  difcover  the  bleeding  arteries, 
it  was  necelTary  to  undo  the  whole ;  the  flap  not  ad- 
hering uniformly  over  the  whole  furface  of  the  flump  ; 
and  the  pain,  inflammation,  and  tenfion,  that  fuper- 
vened  to  this  operation,  being  much  more  fevere  than 
after  the  ufual  method  of  operating. 

Vol.  III.  I  i 


498  Qf  Amputating  at  Chap.  XLIV. 

To  remove  thefe  difficulties,  it  was  propofed,  about 
forty  years  ago,  by  Mr.  O'Halloran,  an  ingenious  fur- 
geon  of  Limeric,  to  drefs  the  flump  and  flap  as  fepa- 
rate  fores  for  the  firft  twelve  days  ;  when  the  rifk  of 
hemorrhagy  being  over,  the  fymptoms  of  pain,  in- 
flammation, and  tenfion,  fubfided,  and  fuppuration  ef* 
tablifhed,  we  are  dire£led  to  turn  the  flap  back  upon 
the  furface  of  the  flump,  and  by  means  of  plafliers, 
compreflion,  and  bandage,  to  fecure  it  in  this  fituation 
till  they  unite. 

By  this  improvement  the  operation  was  rendered 
more  fafe  and  certain  ;  and  it  is  probable  that  it  would 
gradually  have  come  into  general  pra6lice,  if  the  im- 
proved method  of  operating,  that  1  have  already  de- 
fcribed,  had  not  in  the  mean  time  been  introduced : 
but  although  this  will  probably  continue  to  be  gener- 
ally preferred,  yet  in  particular  fituations,  the  opera- 
tion with  the  flap  may  with  much  propriety  be  employ- 
ed. Wherever  the  divided  parts  cannot  be  properly 
covered  with  {kin  in  any  other  manner,  it  ought  cer- 
tainly to  be  done  with  a  flap :  and  this  will  always  be 
the  cafe  in  amputating  the  arm  at  the  flioulder,  and 
the  thigh  at  the  hip  joint,  as  well  as  in  removing  any 
of  the  fingers  or  toes  :  it  may  likewife  by  fome  be  pre- 
ferred to  the  method  of  operating  that  I  have  defcrib- 
ed,  when  it  is  refolved  to  amputate  immediately  below 
the  knee ;  for  the  teguments  being  in  this  part  ex- 
tremely thin,  the  fl;ump  cannot  in  any  other  manner 
be  fufficiently  covered.  But  for  the  reafons  that  I 
have  given,  it  can  never  be  neceflTary,  either  above  the 
knee  ;  immediately  above  the  ankle  ;  nor  in  the  arm 
or  fore-arm.  Some,  however,  may  continue  to  prefer 
it,  even  in  thefe  parts  ;  fo  that  it  will  be  proper  to  de- 
fcribe  the  method  of  doing  it  in  all  of  them ;  which 
I  fliall  therefore  do  in  the  following  Sedions. 


Sea.  VII.  the  Hip  JoinU  499 

SECTION     VII. 

Of  Amputating  at  the  Hip  Joints 

THE  amputation  of  the  thigh  at  the  hip  joint  haa 
always  been  cunfidered  as  one  of  the  molt  haz- 
ardous operations  :  it  has  therefore  been  very  feldom 
performed.  Indeed  furgeons  in  general  have  fpoken 
of  it  as  one  of  thofe  operations  which  authors  might 
defcribe,  but  which  would  never  be  pradifed  ;  and 
when  we  confider  the  great  fize  of  the  blood  vefTels 
which  fupply  thefe  parts  :  the  difficulty  of  command- 
ing the  hemorrhagy  during  the  operation  ;  and  the 
very  extenfive  wound  which,  in  the  ufual  method  of 
operating  muft  necellarily  have  enfued  here  ;  we  will 
not  be  furprifed  at  the  averfion  that  has  generally  pre- 
vailed againfl;  it. 

But  if  thefe  difficulties  can  be  removed  ;  if  danger 
from  hemorrhagy  can  be  prevented  during  the  ope- 
ration, as  well  as  afterwards  ;  if  the  fore  can  be  fo 
completely  covered  with  Ikin  as  to  be  healed  in  the 
courfe  of  a  few  weeks  ;  and  if  cafes  ever  occur  that 
would  otherwife  end  in  the  death  of  the  patient ;  we 
furely  would  not  hefitate  to  advife  it.  Now,  I  hope 
to  make  it  appear,  that  the  operation  may  be  done 
with  very  little  lofs  of  blood  ;  and  that  as  much  fkin 
may  be  faved  as  will  cover  the  fore  entirely  :  and  no 
pradlitioner  will  doubt  of  difeafes  taking  place  at  the 
top  of  the  thigh,  which  cannot  be  removed  but  by 
amputating  the  limb. 

Having  already  treated  fully  of  the  caufes  by  which 
amputation  of  limbs  may  become  neceffary,  I  fhall 
now  refer  to  what  was  faid  upon  that  part  of  the  fub- 
jedb  ;  and  at  prefent  I  fliall  only  obferve,  that  gunfhot 
wounds,  accompanied  with  frattures  of  this  part  of 
the  bone,  fpina  ventofa,  or  caries  of  the  head  of  the 
femur,  will  be  the  moll  frequent  caufes  of  amputa- 
ting at  the  joint  of  the  hip.     When  the  operation  is 

I  I   2 


500  Of  Amptiiatmg  at  Chap.  XLIV. 

to  be  performed,  it  may  be  done  in  the  following 
manner. 

The  patient  fhould  be  placed  upon  a  table  ;  and  it 
will  be  found  that  the  parts  that  are  meant  to  be  di- 
vided will  be  brought  moft  clearly  into  view  by  lay- 
ing him  on  the  found  fide.  In  this  fituation  he  fliould 
be  fecured  by  two  or  three  alliftants,  while  another 
ailiflant  takes  the  management  of  the  limb. 

Let  a  fmall  pad  or  cufhion  be  now  placed  upon  the 
femoral  artery,  immediately  after  it  paffes  out  from 
beneath  Poupart*s  ligament  into  the  thigh  ;  and,  by 
means  of  a  tourniquet  applied  as  near  as  poffible  to 
the  top  of  the  limb,  let  the  circulation  be  completely 
flopped.  Let  the  (kin,  membrana  adipofa,  and  ten- 
dinous facia  of  the  thigh,  be  divided  by  a  circular  in- 
cifion  fix  inches  from  the  top  of  the  thigh  ;  that  is, 
•at  lead  three  inches  beneath  the  circular  band  of  the 
tourniquet.  Let  the  retraced  fkin  be  pulled  an  inch 
upwards ;  and  at  the  edge  of  it  let  the  amputating 
knife  be  applied,  fo  as  with  one  perpendicular  circu- 
lar ftroke  the  mufcles  may  be  cut  down  to  the  bone, 
if  the  mufcles  are  freely  divided,  they  will  retraft  fo 
much  as  to  admit  of  fufficient  fpace  for  fecuring  not 
•only  the  femoral  artery  but  all  the  mufcular  branches. 
This  being  done,  take  a  ftrong  round  edged  fcalpel, 
larger  than  the  common  fize,  and  commencing  at  the 
upper  edge  of  the  circular  cut  on  the  pofterior  part  of 
the  thigh,  make  a  deep  incifion  down  to  the  bone, 
•and  carry  it  up  of  the  fame  depth  to  a  little  above  the 
great  trochanter  into  the  joint.  Let  a  fimilar  cut  be 
made  on  the  oppofite  fide  of  the  Hmb,  at  a  fufficient 
diftance  from  the  femoral  artery,  and  completely 
down  to  the  bone.  Let  the  two  portions  of  fleih  be 
now  diffecled  from  the  bone,  and  the  flaps  formed  by 
them  be  taken  care  of  by  affiftants,  while  any  artery 
that  may  be  cut  ihould  be  tied  as  foon  as  it  is  obferv- 
ed.  The  joint  being  laid  bare,  fome  dexterity  is  re- 
quired to  difengage  the  head  of  the  femur  from  the 
acetabulum  j  for  it  is  rendered  difficult  by  being  tied 


Sea.  VII.  the  Hip  JoinU  501 

down  with  the  llgamentum  rotundum  :  but  by  turn- 
ing the  bone  in  different  diredions,  and  particularly 
by  prefllng  it  inwards,  where  it  yields  moft  readily 
from  the  brim  of  the  acetabulum  being  lowed,  the 
head  of  it  may  be  fo  far  turned  out  of  the  focket  on 
the  oppofite  fide  as  to  admit  of  the  ligament  being 
reached  with  the  point  of  a  fcalpel  or  a  firm  probe 
pointed  biftoury  ;  but  to  accomplifh  this,  the  mufcles 
muft  all  be  previoufly  detached  from  the  bone. 

The  head  of  the  bone  being  taken  out,  and  the 
limb  removed,  we  may  examine  the  ftate  of  the  ace- 
tabulum :  for  if  it  is  found,  our  profpeft  of  a  cure 
will  be  more  favourable  than  if  any  part  of  it  were 
carious.  But  in  whatever  ftate  the  bones  may  be, 
our  treatment  of  the  fore  muft  be  the  fame  :  we  muft 
endeavour  to  cure  it  as  nearly  as  poflible  by  the  firft 
intention  :  for  which  purpofe,  after  removing  all  the 
coagulated  blood  from  the  furface  of  the  wound  ; 
placing  the  muicles  as  nearly  as  poffible  in  their  nat- 
ural fituations  :  and  drawing  the  two  flaps  together, 
fo  as  to  cover  tlie  fore  as  neatly  as  may  be,  they  ftiould 
be  fecured  in  this  fituation  with  three  or  four  futures 
introduced  at  the  moft  proper  points  ;  by  adhefive 
plafters  ;  and  by  proper  comprelfes  retained  with  a 
broad  flannel  roller  pafl^ed  different  times  round  the 
body,  and  fpirally  over  the  ftump  ;  care  being  taken 
to  leave  the  ligatures  upon  the  arteries  of  a  fufiicient 
length  to  admit  of  their  being  afterwards  drawn  out. 

The  patient  fliould  now  be  laid  in  bed,  and  treated 
in  other  refpecls  as  I  have  advifed  in  general  after  the 
operation  of  amputation  :  only  it  muft  be  remarked, 
that  more  than  ordinary  attention  is  required  to  pre- 
vent and  remove  fuch  febrile  fymptoms  as  ufually  fuc- 
ceed  to  amputation  ;  for  where  fuch  a  confiderable 
part  of  the  body  is  fuddenly  taken  away,  almoft  a 
fourth  part  of  the  whole,  we  may  rcafonably  conclude 
that  the  eftedt  produced  by  it  upon  the  fyftem  muft 
be  confiderable.  If  the  patient  is  plethoric,  it  will  be 
proper  to  diminiili  the  quantity  of  blood  ;  in  the  firft 


502  Of  the  Flap  operation      Chap.  XLIV. 

place  by  venefedlon,  and  afterwards  by  a  low  diet : 
indeed  moderate  living  fhould  be  perfevered  in,  if  not 
for  life,  at  lead  for  a  great  length  of  time. 

The  drefiings  may  be  removed  at  the  ufual  time, 
and  in  the  courfe  of  ten  or  twelve  days  the  ligatures 
may  be  all  taken  away ;  at  which  time,  any  part  of 
the  fore  that  remains  open  may  be  covered,  by  draw- 
ing the  fkin  over  it,  and  fecuring  it  with  adhefive  plaf- 
ter.  In  fuch  an  extenfive  foie,  it  is  indeed  probable 
that  matter  may  collecl  in  different  parts  beneath  the 
fkin  ;  for  the  preffure  applied  upon  it,  will  not  be  fo 
equal  as  in  common  cafes  of  amputation  :  but  the  in- 
convenience arifmg  from  this  will  not  be  great ;  for 
if  the  matter  cannot  be  difcharged  by  altering  the 
preffure,  it  will  be  eafily  done  with  the  point  of  a  lan- 
cet, by  which  this  obftruclion  to  the  cure  will  be  re- 
moved. 

At  all  times  this  will  neceffarily  be  confidered  as  a 
very  formidable  operation  ;  but  when  performed  in 
the  manner  I  have  advifed,  much  of  the  hazard,  and 
many  of  the  inconveniencies  ufually  fuppofed  to  at- 
tend it,  will  be  removed  :  nor  fhould  any  praditioner 
accuftomed  to  operate,  hefitate  in  performing  it,  when 
the  life  of  a  patient  will  otherwife  be  endangered.  By 
the  tourniquet,  we  effeftually  command  the  circula- 
tion in  the  Hmb  till  all  the  large  blood  veffels  divided 
by  the  circular  incifion  are  tied  ;  and  by  fecuring  the 
different  arteries  that  are  cut  in  making  the  longitudi- 
nal incifions  as  foon  as  they  appear,  the  lofs  of  blood 
will  be  inconfiderable :  nor  will  there  be  any  rilk  of 
hurting  the  femoral  artery  in  the  courfe  of  feparating 
the  flap  in  which  it  is  feated  from  the  bone,  if  it  is 
done  with  caution. 

It  may  be  alleged,  that  by  this  method  of  operating, 
more  of  the  teguments  and  mufcles  will  be  faved  than 
are  neceffary  for  covering  the  fore ;  but  it  muft  be  re- 
membered, that  the  fore  will  here  be  very  extenfive, 
and  that  the  divided  mufcles  will  retrad  confiderably. 
And  befides,  the  tourniquet  could  not  be  applied  if 


Sed,  VIII.  above  the  Knee.  503 

the  firfl  cut  was  much  higher  than  I  have  direfted  ; 
by  which  the  operation  would  neceflarily  be  rendered 
much  more  dangerous :  nor  can  any  riik  enfue  from 
the  teguments  and  mufcles  being  left  fomewhat  lon- 
ger than  might  juft  be  neceflary,  while  much  incon- 
venience would  arife  from  their  being  deficient. 

In  the  fixth  volume  of  the  Medical  Commentaries 
of  Edinburgh,  a  cafe  is  recorded,  in  which  the  thigh 
was  amputated  at  this  joint  by  Mr.  Kerr,  furgeon  in 
Northampton,  In  this  cafe,  the  divifion  of  the  femo- 
ral artery  was  referved  to  the  lafl  ;  nor  was  the  tour- 
niquet employed.  No  hemorrhagy  indeed  occurred  ; 
but  there  was  furely  more  rifk  of  this  than  if  the  op- 
eration had  been  done  in  the  manner  I  have  advifed  : 
nor  could  the  operator  ufe  fuch  freedom  with  the  bone, 
in  rerrioving  the  head  of  it  from  the  focket,  as  long  as 
the  blood  veflels  remained  undivided.  I  may  remark, 
however,  that  this  cafe  affords  an  inftance  of  this  op- 
eration being  pra£lifed  with  fafety  :  for  although  the 
patient  died,  yet  fhe  lived  eighteen  days  after  the  op- 
eration, and  at  lafl  died  from  a  different  caufe,  when 
all  rifk  of  hemorrhagy  was  over,  and  when  the  fore 
had  even  a  favourable  appearance. 


SECTION     VIII, 
Of  the  Flap  Operation  immediately  above  the  Knee. 

WHEN  this  operation  is  to  be  performed  above 
the  knee,  it  may  be  done  either  with  one  or 
two  flaps,  but  it  will  commonly  fucceed  befl  with  one. 
The  flap  anfwers  befl  on  the  forepart  of  the  thigh  ; 
for  here  there  is  a  fufliciency  of  foft  parts  for  cover- 
ing the  bone,  and  the  matter  paffes  more  freely  off  than 
when  the  flap  is  formed  behind. 

The  patient  being  placed  upon  a  table,  the  tourni- 
quet being  applied  in  the  ufual  way  at  the  top  of  the 


504  Of  the  flap  Operation      Chap.  XLIV. 

thigh,  and  the  teguments  drawn  firmly  up  and  retain- 
ied  by  an  affiftant,  the  extent  of  the  intended  flap  fhould 
be  marked  with  ink.  A  perfon  much  accuflomed  to 
this  operation  may  not  require  this  aliiftance  ;  but  it 
will  be  done  with  more  neatnefs  and  accuracy  if  the 
form  and  extent  of  the  flap  are  previoufly  marked. 

The  extreme  point  of  the  flap  fliould  reach  to  the 
end  of  the  limb,  unlefs  the  teguments  are  in  any  part 
difeafed  ;  in  which  cafe,  it  muft  terminate  where  the 
difeafe  begins,  and  its  bafe  fhould  be  where  the  bone 
is  to  be  fawn.  This;  will  determine  the  length  of  the 
flap  ;  and  we  fhould  be  direded  with  refped  to  the 
breadth  of  it  by  the  circumference  of  the  limb :  for, 
the  diameter  of  a  circle  being  fomewhat  more  than  a 
third  of  its  circumference,  although  a  limb  may  not 
be  exactly  circular,  yet  by  attention  to  this,  we  may 
afcertain  with  fufficient  exaftnefs  the  fize  of  a  flap  for 
covering  a  flump.  Thus,  a  flap  of  four  inches  and  a 
quarter  in  length  will  reach  completely  acrofs  a  fturap 
whofe  circumference  is  twelve  inches ;  but  as  fome 
allowance  muft  be  made  for  the  quantity  of  flvin  and 
mufcles  that  may  be  faved  on  the  oppofite  fide  of  the 
limb,  by  cutting  them  in  the  manner  I  have  directed, 
and  drawing  them  up  before  fawing  the  bone ;  and 
as  it  is  a  point  of  importance  to  leave  the  limb  as  long 
as  poffible,  inftead  of  four  inches  and  a  quarter,  a 
limb  of  this  fize,  where  the  firft  incifion  is  managed 
in  this  manner,  will  not  require  a  flap  longer  than 
three  inches  and  a  quarter,  and  fo  in  proportion  ac- 
cording to  the  fize  of  the  limb.  The  flap  at  its  bafe 
■fhould  be  as  broad  as  the  breadth  of  the  limb  will  per- 
mit, and  fhould  be  continued  nearly,  although  not  al- 
together, of  the  fame  breadth  to  within  a  little  of  its 
termination,  where  it  fnould  be  rounded  off"  fo  as  to 
correfpond  as  exactly  as  may  be  with  the  figure  of  the 
fore  on  the  back  part  of  the  limb.  This  being  mark- 
ed out,  the  furgeon  ftanding  on  the  outfide  of  the 
limb  fhould  pafli  a  ftraight  double  edged  knife  with  a 
Iharp  point  to  the  depth  of  the  bone,  by  entering  the 


Scd:.  VIII.  abo-ve  the  Knee.  505 

point  of  it  at  the  outfide  of  the  bafe  of  the  intended 
flap  ;  and  carrying  the  point  clofe  to  the  bone,  it  muft 
here  be  pufhed  through  the  teguments  at  the  mark  on 
the  oppofitc  fide.  The  edge  of  the  knife  muft  now 
be  carried  downwards,  in  fuch  a  diieflion  as  to  form 
the  flap  according  to  the  figure  marked  out ;  and  as 
it  draws  towards  the  end,  the  edge  of  it  fliould  be 
fomewhat  raifed  from  the  bone,  fo  as  to  make  the  ex- 
tremity of  the  flap  thinner  than  the  bafe  ;  by  which 
it  will  apply  with  more  neatnefs  to  the  furface  of  the 
fore.  The  flap  being  fupported  by  an  afllllant,  the 
teguments  and  mufcles  of  the  other  parts  of  the  limb 
fliould,  by  one  Itroke  of  the  knife,  be  cut  down  to  the 
bone  about  an  inch  beneath  where  the  bone  is  to  be 
fawn ;  and  the  mufcles  being  feparated  to  this  height 
from  the  bone  with  the  point  of  the  knife,  the  foft 
parts  mud  all  be  fupported  with  the  leather  retraftors, 
Plate  XCVII.  hg.  4.  till  the  bone  is  fawn,  and  any 
fplinters  that  may  be  left,  are  cut  off.  All  the  arteries 
that  discharge  much  blood  muft  now  be  fccured  in 
the  ufual  way  with  the  tenaculum,  the  ligatures  being 
left  of  a  fufiicient  length  for  hanging  out  at  the  tAg& 
of  the  flap. 

The  fl<in  and  mufcles  fliould  now  be  drawn  down 
and  fecurcd  with  a  flannel  or  cotton  roller,  in  the  man- 
ner I  have  advifed  when  a  leg  is  amputated  with  a  cir- 
cular incifion  ;  and  the  flap  may  now  be  laid  down 
over  the  furface  of  the  fore,  fo  as  to  eft'edl  a  cure  a3 
much  as  poflible  by  the  firft  intention ;  or  it  may  be 
dreflTed  as  a  feparate  fore,  agreeably  to  the  pradice  of 
Mr.  O'Halloran,  according  to  the  judgment  of  the  op- 
erator. If  the  flap  is  to  be  applied  immediately,  the 
coagulated  blood  fliould  be  carefully  fponged  out,  and 
it  fliould  be  fecured  to  the  mufcles  and  teguments  fur- 
rounding  the  reft  of  the  ftump  by  three  or  four  futures 
paflfed  at  leaft  three  quarters  of  an  inch  into  the  niuf- 
cular  part  of  it :  but  care  fliould  be  taken  not  to  draw 
the  ligatures  fo  tight  as  to  create  much  irritation  or 
pain.     The  under  part  of  the  ftump  fliould  now  be 


5o6  Of  the  Flap  Operation      Chap.  XLIV. 

covered  with  a  large  pledget  of  common  cerate  ;  and 
a  culhion  of  foft  tow  being  laid  over  it,  the  whole 
ihould  be  fecured  in  the  manner  I  have  formerly  ad- 
vifed,  with  crofs  flraps  of  linen  and  a  few  turns  of  a 
circular  roller. 

In  three  or  four  days,  the  dreflings  may  be  renew- 
ed ;  and  as  foon  as  the  ligatures  are  all  removed,  and 
the  tenfion  and  inflammation  induced  by  the  operation 
abated,  any  part  of  the  fore  that  was  not  covered  at 
firfl  may  now  have  the  fkin  drawn  over  it,  and  fecur- 
ed with  adhefive  plaflers. 

But  if  Mr.  O'Halloran's  method  is  to  be  adopted, 
the  eafielt  mode  of  proceeding  is  this.  The  mufcles 
and  teguments  being  drawn  down  and  fecured  with 
the  roller,  let  the  whole  furface  of  the  ftjump  be  cov- 
ered with  a  pledget  of  foft  lint  fpread  on  both  fides 
with  any  foft  emollient  ointment ;  let  the  flap  be  laid 
down  upon  this ;  and  another  pledget  of  the  fame 
kind  being  laid  over  the  whole  Vv^ith  a  cufliion  of  tow 
and  a  comprefs  of  foft  linen,  the  crofs  fl:raps  and  cir- 
cular roller  fliould  be  employed  to  fupport  them,  but 
with  gentle  preflfure.  At  the  end  of  three  or  four  days, 
the  dreflings  may  be  renewed  in  the  fame  manner  ;  and 
about  the  twelfth  or  fourteenth  day,  or  whenever  the 
tenfion  induced  by  the  operation  is  removed,  the  lig- 
atures being  all  taken  out,  and  a  proper  luppuration 
efl:abHflied,  the  flap  may  be  brought  into  contad  with 
the  fore  beneath  with  a  view  to  make  them  unite.  For 
this  purpofe,  any  matter  that  may  be  obferved  upon 
the  furface  of  either  of  them  fliould  be  gently  remov- 
ed with  a  foft  fponge  ;  and  the  flap  being  laid  down 
with  as  much  exactnefs  as  poflible,  it  may  either  be 
fecured  with  adhefive  plafl:ers  fupported  by  the  band- 
age above  mentioned,  or  two  or  three  futures  may  be 
employed  for  it.  This  lafl;  method  will  give  more 
pain  than  the  other  ;  but  this  will  be  amply  compen- 
lated  by  the  flap  being  retained  with  more  accuracy  in 
its  fituation. 

Farther  experience  mufl  evince  which  of  thef^  me- 


SeOi.  VIII.  above  ihc  Knee,  507 

thods  fhould  be  preferred,  for  as  yet  it  is  not  deter- 
mined. It  is  my  own  opinion,  that  the  fecondary 
union  recommended  by  Mr.  O'Halloran  is  the  beft : 
for  the  pain,  tendon,  and  inflammation  that  enfue  from 
the  other,  run  often  fo  high  as  to  render  it  neceflary 
to  remove  the  drefTmgs  and  even  the  ligatures  ;  by 
which  much  additional  trouble  is  given  to  the  pradi- 
tioner,  and  much  diftrefs  to  the  patient :  whereas, 
when  the  tenfion  and  inflammation  are  gone  before 
the  flap  is  laid  down,  little  or  no  pain  is  induced  by 
it ;  nor  is  the  cure  eft'e6led  in  this  manner  more  tedi- 
ous :  on  the  contrary,  it  would  appear  to  be  in  gener- 
al accompliflied  more  quickly  in  this  way  than  in  the 
other.  Even  where  the  flap  has  not  been  applied  to 
the  fore  till  the  fourteenth  day,  the  cure  has  been  com- 
pleted before  the  fourth  week  :  whereas,  few,  if  any, 
cures,  have  been  eft'eftcd  fo  early  where  the  flap  was 
applied  immediately  after  the  operation. 

In  operating  with  two  flaps,  the  following  is  perhaps 
the  eafiefl:  method  :  the  patient  being  placed  upon  a 
table,  and  the  tourniquet  applied,  let  the  fkin  be  drawn 
up  by  an  afliflant,  and  a  circular  incifion  made  through 
the  teguments  and  mufclcs  down  to  the  bone  at  the 
inferior  part  of  the  limb,  with  the  edge  of  the  knife 
turned  obliquely  upwards  :  let  the  fharp  pointed  knife, 
mentioned  above,  be  now  puflied  through  the  flvin  and 
mufcles  on  one  fide  of  the  limb  down  to  the  bone,  at 
that  part  where  it  is  to  be  fawn  ;  and  the  under  edge 
of  the  knife  being  turned  obliquely  outwards,  let  the 
mufcles  be  divided  down  to  the  circular  incifion.  The 
teguments  and  nmfcles  on  the  oppofite  fide  of  the 
limb  mufl:  now  be  divided  by  a  fimilar  incifion,  when 
any  of  the  intermediate  foft  parts  that  may  have  been 
left  mufl;  likewife  be  cut  ;  and  the  bone  being  fawn, 
and  the  vefl^els  fecured  with  ligatures,  the  cure  may 
either  be  attempted  by  laying  the  flaps  together  imme- 
diately, or  they  may  be  kept  feparate  twelve  or  four- 
teen days,  and  treated  afterwards  in  the  manner  I  have 
advifed  above. 


5o»  Of  the  Flap  Operation,  Isfc.     Chap.  XLIV. 

SECTION    IX. 

Of  the  Flap  Operation  below  the  Knee* 

IN  fpeaking  of  this  operation  below  the  knee,  it  is 
not  neceflary  to  defcribe  all  the  fteps  of  it.  The 
views  of  the  operator  are  the  fame  here  as  in  operating 
above  the  knee,  and  the  method  of  effe^Ling  them  is 
nearly  fimilar.  After  the  previous  fleps  of  the  opera- 
tion are  taken,  the  fize  and  form  of  a  flap  fufHcient  to 
cover  a  conllderable  part  of  the  fore  muft  be  marked 
out  with  ink,  and  this  muft  be  feparated  from  the  parts 
beneath  in  the  manner  1  have  already  advifed  :  the 
reft  of  the  foft  parts  muft  now  be  divided,  taking,  care 
to  fave  as  much  of  the  teguments  on  the  fide  of  the 
limb  oppofite  to  the  flap  as  with  the  flap  itfelf  will  near* 
ly  or  entirely  cover  the  fore  ;  and  the  cure  muft  after- 
wards be  conduced,  either  by  applying  the  flap  im- 
mediately, or  after  the  fymptoms  of  pain,  tenfion  and 
inflammation  induced  by  the  operation  are  gone,  and 
treated  in  the  manner  advifed  in  the  laft  fe6lion. 

It  muft  be  obferved,  however,  in  operating  beneath 
the  knee,  that  the  flap  cannot  be  formed  on  the  fore- 
part of  the  hmb  as  is  done  in  the  thigh  ;  for  op  this 
part  of  the  leg  there  is  no  mufcular  fubftance ;  and 
for  this  reafon,  we  are  advifed  by  authors  to  form  the 
6ap  on  the  back  part  of  the  leg.  But  this  is  liable  to 
one  very  important  objedion,  the  difficulty  of  prevent- 
ing matter  from  lodging  between  the  flap  and  the  fore 
after  they  are  brought  in  contad  ;  for  it  muft  be  re- 
marked, that  it  is  moderate  preifure  only  that  we  dare 
venture  to  apply  to  the  flap  ;  fo  that  it  is  fcarcely  pof- 
fible  to  prevent  the  matter  from  collecting  where  it 
does  not  find  a  free  vent  below. 

Inftead  of  forming  the  flap  from  the  mufclcs  of  the 
back  part  of  the  leg,  it  may  be  done  with  more  pro- 
priety upon  the  outfide  of  the  limb,  where  there  is  a 


Sed.  X.         Of  Amputating  the  Foot,  tffc.  509 

fufficient  quantity  of  mufcular  fubftance  for  this  pur- 
pofe.  The  point  of  the  knife  fliould  be  entered  on 
the  outfide  of  the  ridge  of  the  tibia  at  the  part  where 
the  bone  is  to  be  fawn ;  and  being  carried  backwards 
in  a  dired  Hne,  and  at  a  proper  depth  to  the  oppofite 
fide  of  the  bafe  of  the  flap,  the  edge  of  it  muft  after- 
wards be  carried  down  the  line  previoufly  marked  w  ith 
ink  as  a  direction  for  the  form  and  length  of  it.  In 
this  manner  the  bones  may  be  covered  with  a  flap  fuf- 
ficiently  thick,  while  the  matter  that  forms  in  the  pro- 
grefs  of  the  cure,  finding  a  ready  outlet  by  the  inferi- 
or edge  of  the  flap,  will  not  readily  lodge. 

In  operating  immediately  above  the  ankle,  we  are 
under  the  necefiity  of  leaving  the  flap  behind,  for  there 
is  not  a  fufficicncy  of  foft  parts  to  admit  of  it  in  any 
other  part.  But  I  have  elfewhere  obferved,  that  the 
leg  fhould  never  be  taken  off  fo  immediately  above 
the  ankle,  as  it  leaves  the  ftump  too  long  for  a  ma- 
chine to  be  rightly  fitted  to  it  for  walking :  but  at 
nine  inches  from  the  condyles  of  the  femur,  which  in 
an  adult  is  the  mofl  proper  length  for  this  purpofe, 
the  flap  may  with  propriety  be  formed,  in  the  manner 
I  have  mentioned,  on  the  outfide  of  the  leg. 


SECTION     X. 

Of  Amputating  the  Fcoty  Tecs,  and  Fingers^ 

WHEN  the  whole  foot  is  difeafed,  it  becomes 
neceflfary  to  take  oil  the  limb  at  the  part  I 
have  mentioned  above  the  ankle;  nay,  this  fliould  be 
done  even  where  the  parts  about  the  joint  are  found, 
if  all  the  refl:  of  the  foot  is  difeafed  :  for  although  fome 
have  advifed  the  foot  to  be  amputated  at  the  joint  of. 
tlic  ankle,  yet  the  praflice  fliould  not  be  adopted,  as 
the  fore  cannot  be  properly  covered,  nor  is  the  ftump 
^'hcn  of  this  length  fo  ufcful :   but  wlicn  a  confidera- 


5IO  Of  Amputating  the  Chap.  XLIV* 

ble  part  of  the  foot  remains  found,  it  ought  undotibt* 
edly  to  be  faved,  and  the  difeafed  part  of  it  only  re- 
moved. I  have  feen  a  whole  foot  taken  off,  where 
two  of  the  metatarfal  bones  only  were  difeafed  :  while, 
on  the  contrary,  it  (hould  be  held  as  a  fixed  rule,  to 
remove  the  difeafed  parts  alone,  even  where  two  of 
thefe  bones  only  remain  found  ;  for  with  the  afTiftance 
of  a  flioe  properly  fluffed,  and  a  firm  unyielding  fole, 
even  a  very  fmall  part  of  the  foot  proves  ufeful  in 
walking ;  efpecially  when  the  bones  on  the  infide  of 
the  foot,  or  thofe  correfponding  to  the  great  toe,  and 
thofe  next  to  it,  are  left. 

When  the  middle  part  only  of  the  foot  is  difeafed, 
the  metatarfal  bones  on  each  fide  remaining  found, 
thefe  fliould  be  left,  and  the  difeafed  part  only  taken 
out.  In  this  cafe,  the  bones  fhould  be  taken  out  at 
the  joint,  whether  they  are  difeafed  through  their 
whole  length  or  not ;  for  although  inftruments  might 
be  invented  for  cutting  even  a  fingle  bone  acrofs  in 
the  centre  of  the  foot,  the  operation  would  neceffarily 
be  much  more  tedious,  and  more  painful,  than  the 
removal  of  the  bone  at  the  joint,  at  the  fame  time  that 
little  or  no  advantage  would  be  derived  from  faving  a 
fmall  portion  at  the  end  of  it.  But  where  one,  two 
or  three  of  the  bones  on  either  fide  of  the  foot  are  on- 
ly partially  difeafed,  as  in  this  cafe  it  becomes  an  ob- 
ject to  fave  as  much  of  the  foot  as  pofTible,  the  opera- 
tion fliould  be  fo  conducted  that  the  bones  may  be 
fawn  acrofs  nearly  at  the  termination  of  the  difeafed 
parts. 

In  every  cafe  of  amputation,  it  is  an  obje£l  of  im- 
portance to  fave  as  much  fkin  as  will  cover  the  fore ; 
efpecially  in  amputating  any  part  of  the  foot  where 
the  effect  of  friction  is  much  to  be  dreaded  in  walk- 
ing. In  making  the  incifion,  therefore,  at  that  part 
of  the  bone  where  the  faw  is  to  be  applied,  it  fhould 
be  done  in  fuch  a  manner,  that  a  flap  may  be  faved 
of  a  fufficient  fize  for  covering  the  fore.  With  pro- 
per attention  this  may  always  be  done,  nor  is  it  often 


Se£t.  X.  Foot,  Toes,  a?id  Fingers,  5 1 1 

difficult :  for  the  flap  may  be  formed  either  above  or 
below,  or  on  one  fide  of  the  toe,  according  as  the  teg- 
uments are  found  or  otherwife.  But  it  is  proper  to 
remark,  that  where  the  ikin  is  found,  it  aniwers  beft 
to  fave  it  below,  for  in  this  fituation  it  is  firmer,  and 
therefore  more  able  to  rcfifl  the  etle^is  of  prefTure. 

This  operation  is  mofl  eafily  performed  when  the 
patient  is  placed  upon  a  table.  The  tourniquet  fliould 
be  applied  above  the  knee,  with  a  comprefs  placed 
upon  the  artery  in  the  ham  :  the  linib  fliould  be  firm- 
ly fecured  by  afliflants ;  and  on  fawing  the  bone,  a 
piece  of  pafteboard,  or  thin  fplint  of  timber,  fhould 
be  inferted  between  it  and  the  contiguous  found  bone, 
to  protect  the  latter  from  the  teeth  of  the  inftrument. 

The  difeafed  parts  being  removed,  and  the  divided 
arteries  fecured,  the  flap  fhould  be  applied  as  exadlly 
as  pofllble  to  the  fore,  and  retained  with  flips  of  adhe- 
five  plafter  and  gentle  prefTure  with  a  flannel  roller. 
If  futures  are  employed,  they  fhould  be  inferted  in 
fuch  a  manner  as  to  avoid  the  flexor  and  extenfor  ten- 
dons of  the  toes  and  foot. 

In  amputating  the  toes  and  fingers,  the  operation 
was  formerly  done  by  one  flroke  with  a  chifel  and 
mallet ;  but  this  is  liable  to  many  objedions,  and  has 
been  long  in  difufe.  In  general,  fingers  and  toes  are 
amputated  in  the  fame  manner  with  the  larger  extre- 
mities, either  by  preferving  a  flap  fufHcicnt  for  cover- 
ing the  fore,  and  afterwards  dividing  the  bone  with  a 
fmall  fpring  faw,  rcprcfented  in  Plate  XCVII.  fig.  i. 
or  by  the  double  incifion,  performed  in  the  manner  I 
have  advifed  in  SeQion  IV.  of  this  Chapter.  But  in- 
ftead  of  this,  it  has  for  feveral  years  been  the  praftice 
of  fome  individuals,  to  amputate  fingers  and  toes  at 
the  joints  ;  and  whoever  will  give  it  a  fair  trial,  will 
readily  prefer  it.  The  patient  being  placed  upon  a 
table,  and  the  limb  properly  fecured,  a  flap  fhould  be 
marked  with  ink  of  a  fuflicient  fize  for  covering  the 
fore.  This  being  diflefted  from  the  bone  with  a  fcal- 
pel,  and  fupported  by  an  afhftant,  a  circular  incifion 


512  Of  Amputallng  the         Chap.  XLIV. 

Is  then  made  through  the  reft  of  the  foft  parts  a  little 
below  the  joint,  and  on  a  line  with  the  bafe  of  the 
flap.  The  lateral  ligament  is  now  to  be  cut ;  and  in 
order  to  determine  the  point  at  which  this  fhould  be 
done,  an  afliftant  (hould  be  directed  to  move  the  fin- 
ger. This  ligament  being  divided,  the  bones  are  eafily 
diflocated,  when  the  remainder  of  the  operation  may- 
be quickly  iinifhed.  If  an  artery  is  to  be  tied,  it  fhould 
be  done  with  the  tenaculum.  The  flap  muft  be  ap- 
plied to  the  fore,  and  fecured  as  neatly  as  poflible  with 
adhefive  plafters,  and  moderate  preflure  with  a  flannel 
roller. 

The  only  chjedicn  that  has  been  made  to  this  prac- 
tice is,  the  fuppofed  uncertain  union  of  the  contiguous 
foft  parts  with  cartilage.  But  we  now  know,  that 
there  is  no  caufe  for  this  apprehenfion,  and  that  a  flap 
will  unite  as  readily  with  cartilage  as  with  bone,  at 
leaft  I  have  uniformly  obferved  this  to  be  the  cafe ; 
and  we  find  from  Mr.  Alanfon's  publication,  that  the 
praftice  has  proved  very  fuccefsful  in  the  courfe  of 
his  experience. 


SECTION     XI. 

Of  Amputating  the  Ann  at  the  fo'tnt  of  the  Shoulder, 

THIS  operation  having  always  been  confidered  as 
hazardous  and  difficult  to  perform,  it  has  not 
frequently  been  attempted  :  but  although  it  fhould 
never  be  advifed  when  our  purpofe  can  be  accomplifh- 
ed  by  amputating  lower,  yet  no  praditioner  of  mod- 
ern times  will  decline  it,  when  the  life  of  a  patient 
cannot  in  any  other  manner  be  faved.  AbfceflTes  in 
the  joint,  caries  of  the  humerus  reaching  to  the  joint, 
compound  fraftures  extending  to  the  head  of  the 
bone,  gunfliot  wounds  and  mortification,  may  render 
amputation  of  the  arm  at  the  fhoulder  neceffary. 


Sed.  XI.  Arm  at  the  Shoulder.  513 

The  operation  may  be  performed  with  fafety  by  any 
furgeon  of  fteadinefs  and  experience,  and  who  is  pof- 
felfed  of  an  accurate  knowledge  of  the  anatomy  of  the 
Joint  and  contiguous  parts. 

It  may  be  done  in  different  ways  ;  but  the  follow- 
ing I  believe  to  be  the  beft. 

The  patient  (hould  be  placed  upon  a  table  of  a  con- 
venient height,  covered  with  a  mattrefs  and  blanket ; 
and  he  fliould  be  laid  upon  his  back,  and  properly  fe- 
cured  by  afliflants,  as  near  as  poffible  to  one  fide  of 
the  table. 

The  next  obje*^  is  to  guard  againfl  hemorrhagy : 
for  this  purpofe  the  tourniquet  might  be  placed  upon 
the  upper  part  of  the  limb,  in  a  manner  fimilar  to 
what  I  have  propofed  in  amputating  at  the  hip  joint. 
But  here  it  is  unnecefl'ary,  as  the  blood  may  be  com- 
pletely flopped  in  its  flow  to  the  arm,  by  comprefling 
the  fubclavian  artery  as  it  paffes  over  the  firft  rib  :  for 
this  purpofe,  an  alliflant  fhould  be  properly  placed 
with  a  firm  cufhion  or  comprefs  applied  upon  the 
courfe  of  this  artery  diredly  above  the  clavicle,  who 
with  his  finger  fhould  make  fuch  a  degree  of  preffure 
as  may  be  required  :  it  will  readily  be  known  whether 
it  anfwers  or  not,  by  its  influence  on  the  pulfe  at  the 
wrifl. 

The  circulation  being  flopped,  the  difeafed  fhoul- 
der  fhould  be  made  to  project  fomewhat  over  the  fide 
of  the  table  ;  and  the  arm  being  ftretched  out  and 
fupported  by  an  affiflant  at  nearly  a  right  angle  with 
the  body,  a  circular  cut  fhould  be  made  through  the 
fkin  and  cellular  fubflance  jufl  at  the  infertion  of  the 
deltoid  mufcle  into  the  humerus.  The  teguments  may 
be  allowed  to  retraft  about  half  an  inch  ;  and  at  the 
edge  of  the  retradled  fkin,  the  knife  may  be  applied  fo 
as  to  divide  the  mufcles  with  a  perpendicular  circular 
cut  down  to  the  bone.  Thus  far  we  proceed  with  the 
common  amputating  knife ;  but  the  remainder  of  the 
operation  fhould  be  finifhed  with  a  fcalpel.     With  a 

Vol.  III.  K  k 


514  Of  Amputattng  the         Chap.  XLIV, 

firm  round  edged  fcalpel  a  perpendicular  inclfion 
(hould  now  be  made  down  to  the  bone,  commencing 
at  the  acromion,  about  half  way  between  the  centre 
of  the  deltoid  mufcle  and  the  inner  edge  of  it,  and  ter- 
minating in  the  circular  incifion  about  an  inch  above 
or  rather  on  the  outfide  of  the  brachial  artery.  This 
being  done,  a  fimilar  cut  muft  be  made  on  the  back 
part  of  the  arm,  commencing  at  the  fame  height  with 
the  other,  and  ending  in  the  circular  incifion.  This 
fhould  be  at  fuch  a  diftance  from  the  firft,  that  the 
two  flaps  formed  by  them  both  may  be  nearly  of  an 
equal  breadth.  The  brachial  artery  fhould  be  tied  as 
foon  as  it  is  cut  by  the  circular  incifion  through  the 
mufcles ;  and  any  anaftomofing  mufcular  branches  of 
arteries jthat  may  be  cut  on  the  upper  and  back  part 
of  the  joint,  fhould  be  tied  immediately  on  being  ob- 
ferved.  The  two  flaps  fliould  now  be  feparated  from 
the  bonCj  care  being  taken  to  avoid  the  large  artery  in 
diflTedling  off  that  part  of  the  flap  with  which  it  is  con- 
nected. An  afl^iflant  mufi:  fupport  the  flaps  fo  as  to 
bring  the  capfular  ligament  of  the  joint  into  view  ; 
when  an  opening  being  made  into  it,  the  head  of  the 
bone  will  be  eafily  diflocated  by  drawing  the  arm  back- 
ward ;  and  this  being  done,  the  operation  will  be  ea- 
fily finifhed,  by  dividing  the  remaining  part  of  the  lig- 
ament. 

Any  arteries  that  may  have  been  cut  about  the  joint 
being  tied,  the  ligatures  hanging  out  at  the  moll  de- 
pending part  of  the  wound,  and  the  parts  cleared  of 
coagulated  blood,  the  two  flaps  fhould  be  laid  togeth- 
er fo  as  to  cover  the  joint  as  neatly  as  poflible,  and  re- 
tained in  their  fituation  with  two  or  more  futures.  A 
pledget  of  lint  fpread  with  any  emollient  ointment 
fliould  now  be  laid  over  the  joint ;  and  a  foft  cufhion 
of  tow  or  lint,  with  a  comprefs  of  old  linen,  being  ap- 
plied over  the  whole,  a  flannel  roller  fliould  be  em- 
ployed to  make  moderate  prefl'ure  upon  the  joint ;  by 
which  the  flaps  will  be  kept  in  contact  witli  the  parts 
beneath,  which  will  not  only  facilitate  their  union,  but 


Seft.  XI.  Ar7n  at  the  Shoulder.  515 

will  be  the  mofl:  efFedual  method  of  preventing  the 
lodgment  of  matter. 

In  other  refpecls,  the  patient  fliould  be  treated  as  I 
have  advifed  in  the  preceding  fections  when  fpeaking 
of  amputation  in  the  lower  extremities.  With  a  view 
to  prevent  any  rifk  from  hemorrhagy  after  the  opera- 
tion^  an  affiftant  of  experience  fliould  fit  with  the  pa- 
tient for  the  firfl  two  or  three  days,  with  diredions  to 
apply  preffure  above  the  clavicle  in  the  event  of  any 
confiderable  quantity  of  blood  being  difcharged,  till 
the  bleeding  veflTel  can  be  fecured  with  a  ligature.  In 
the  courfe  of  eight  or  ten  days,  the  ligatures  upon  the 
arteries  will  come  eafily  away.  If  matter  colleds  be- 
neath any  part  of  the  fkin,  it  mud  be  difcharged  ;  and 
if  the  patient  is  healthy,  and  no  untoward  circumftance 
happens,  a  cure  may  foon  be  expelled. 

Till  of  late,  it  was  the  practice  in  this  operation  to 
tie  the  brachial  artery  and  veins  with  a  Hgature  before 
proceeding  farther.  This  gave  much  unneceflary 
pain,  at  the  fame  time  that  it  did  not  render  the  pa- 
tient more  fecure.  In  the  way  I  have  mentioned,  the 
operation  may  be  performed  with  no  rifk  from  the  he- 
morrhagy ;  and  by  tying  the  artery  at  the  extremity 
of  the  flap,  feveral  mufcular  branches  will  be  faved 
that  would  be  deflroyed  by  tying  it  near  the  axilla. 

Mr.  Bromfield,  in  the  firfl  volume  of  his  Obferva- 
tions  and  Cafes,  has  given  the  beft  account  yet  publifh- 
ed  of  this  operation.  The  principal  difference  between 
his  method  of  doing  it  and  the  one  that  I  have  de- 
fcribed,  confifts  in  the  latter  being  more  fimple,  and 
therefore  more  eafily  performed.  By  dividing  the 
mufcles  down  to  the  bone  with  a  circular  incifion,  the 
operation  is  more  fpeedily  done  than  by  cutting  firfl 
one  mufcle  and  then  another,  in  the  manner  mention- 
ed by  Mr.  Bromfield.  And  as  the  attachments  of 
the  latiflimus  dorfi,  the  deltoid  and  pedoral  mufcles, 
are  removed  by  the  arm  being  taken  away,  there  is  no 
neceflity  for  proceeding  with  flownefs  and  caution  in 
K  K  2 


5i6  Of  Amputating  the  Amu     Chap.  XLIV. 

dividing  them  ;  nor  is  it  neceffai-y  to  employ  two  lig- 
atures upon  the  brachial  artery,  one  confiderably  high- 
er than  the  other,  as  is  advifed  by  that  author ;  one 
ligature  applied  in  the  ufual  way  with  the  tenaculum 
is  quite  fufficient,  if  it  is  done  with  care  and  attention. 
And  Mr.  Alanfcn  very  properly  obferves,  in  fpeaking 
of  this  operation,  that  there  is  no  necellity  for  fcrap- 
ing  oif  the  cartilage  from  the  acetabulum  of  the  joint, 
as  is  recommended  by  Mr.  Bromfield  ;  for  it  is  found, 
by  experience,  as  I  have  obferved  in  the  laft  Sedion, 
that  the  teguments  adhere  to  cartilages  as  readily  as 
to  bone. 


SECTION    XII. 

Of  A?7iputating  the  Ann. 

THE  general  obfervations  I  have  made  upon  the 
method  of  amputating  the  thigh  and  leg,  apply 
equally  to  the  amputation  of  the  arm  and  fore-arm. 
At  prefent,  therefore,  I  Ihall  only  obferve,  that  in  am- 
putating the  arm,  no  more  of  it  fhould  be  removed 
than  is  difeafed  ;  for  the  longer  the  ftump  is,  the  more 
ufeful  it  proves  j  and  the  fame  attention  fhould  be  giv- 
en to  the  faving  of  teguments  for  covering  the  fore 
that  I  have  advifed  in  amputating  the  leg.  But  it  is 
proper  to  remark,  that  this  may  always  be  done  both 
in  the  arm  and  fore-arm  without  the  affiftance  of  a 
flap  :  for  there  is  in  every  part  of  both  a  fufficiency  of 
mufcles  and  cellular  fubftance,  for  admitting  of  the 
fore  being  completely  covered  by  amputating  with  the 
double  incifion,  in  the  manner  I  have  pointed  out  for 
this  operation  upon  the  thigh  ;  and  wherever  this  can 
be  done,  it  fhould  be  preferred  to  the  method  of  op- 
crating  with  a  flap. 


Chap.  XL  V.     Of  removing  Ends  of  Bones*  517 


CHAPTER     XLV. 


OF  REMOVING  THE  ENDS  OF   BONKS  IN  DISEASES   OF 
THE  JOINTS. 


THE  amputation  of  limbs  Is  more  frequently  ad- 
vifed  for  difeafes  of  the  joints  than  for  any  oth- 
er caufe  ;  and  as  this  often  happens  where  the  reft  of 
the  Hmb  is  found,  it  were  to  be  wifhed,  that  with  fafe- 
ty  and  propriety  we  could  remove  fuch  parts  as  are 
difeafed,  and  leave  thofe  that  are  found.  In  compound 
fractures  and  diflocations,  the  ends  of  large  bones  have 
frequently  been  fawn  off,  when  fuch  parts  of  them 
have  protruded  as  could  not  be  replaced.  The  defi- 
ciency thus  produced,  has  in  moft  inftances  been  fup- 
plied  by  nature ;  and  thus  the  limbs  have  remained 
almoft  equally  ufeful  as  before.  In  a  few  cafes,  too, 
of  difeafed  joints,  a  cure  has  been  obtained  by  the  head 
of  a  bone  being  fawn  off.  Among  other  inftances  of 
this  to  be  met  with  in  books,  a  remarkable  one  is  re- 
corded by  a  very  ingenious  and  expert  furgeon,  Mr. 
White  of  Manchefter,  who  preferved  an  arm  by  faw- 
ing  off  the  head  of  a  difeafed  humerus.*  But  Mr, 
Park  of  Liverpool,  was  the  firft  who  ventured  to  pro- 
pofe  it  as  a  general  remedy  in  aft'edtions  of  the  joints.f 
Whether  or  not  it  will  ftand  the  teft  of  experience, 
farther  trials  muft  determine ;  but  in  the  mean  time, 
the  public  are  much  indebted  to  Mr.  Park  for  the 
pains  he  has  taken  to  introduce  a  lefs  formidable  rem- 
edy in  place  of  amputation. 

•  Vide  Cafes  in  Surgery  with  Remarks,  Part  I.  by  Charlci  White, 
F.  R.  S.  &c. 

t  Vide  An  account  of  a  new  method  of  treating  difeafes  of  the  joints  of 
the  knee  and  elbow,  by  H.  Park. 


51 S  Of  removing  Ends  of         Chap.  XL  V. 

What  Mr.  Park  propofes  is,  that  inftead  of  ampu- 
tating a  limb  for  any  external  violence  done  to  a  joint, 
for  a  white  fwelling,  a  caries,  or  any  other  affection, 
that  the  difeafed  ends  of  the  bones  fhould  be  fawn  oft' ; 
when  nature,  he  thinks,  will  commonly  fupply  the  de- 
ficiency of  bone  ;  by  which  the  limb  will  be  preferv- 
ed,  and  will  prove  more  ufeful  than  any  machine  that 
artifts  can  invent. 

Mr.  Park  fuppofes  that  this  operation  will  be  chief- 
ly applicable  to  affedions  of  the  knee  and  elbow,  and 
more  particularly  to  thofe  of  the  latter  ;  and  he  relates 
a  cafe  of  white  fwelling  of  the  knee  in  which  it  was 
pradifed  with  fuccefs  :  the  under  extremity  of  the 
femur  and  the  upper  end  of  the  tibia  were  fawn  off"; 
no  artery  of  importance  was  injured  j  and  the  vacan- 
cy produced  by  the  removal  of  the  ends  of  the  bones 
was  fupplied  with  callus :  in  the  courfe  of  ten  weeks, 
a  cure  of  the  fore  was  obtained  ;  the  hmb  became  fo 
firm  that  the  man  has  fmce  been  able  to  go  to  fea  as 
a  failor,  and  he  does  not  even  ufe  a  crutch. 

This,  however,  is  the  moft  favourable  view  of  the 
propofal ;  and  it  is  proper  to  remark,  that  in  the  courfe 
of  the  cure,  much  perplexity  occurred  from  various 
circumftances  ;  particularly  from  the  difficulty  of  pre- 
ferving  the  limb  in  a  fteady  fixed  fituation  ;  from  the 
great  depth  of  the  wound  ;  from  the  lodgment  of  mat- 
ter ;  and  from  the  formation  of  finufes.  By  much  at- 
tention on  the  part  of  Mr.  Park,  all  thefe  difficulties 
were  fur  mounted  ;  but  although  the  merits  of  the  op- 
eration muft  be  determined  by  farther  trials,  yet  the 
rifk  attending  it  appears  to  be  fo  great,  that  there  is 
much  reafon  to  think  that  it  \viU  never  be  generally 
practifed. 

For  a  more  particular  detail  of  the  method  of  do- 
ing it,  and  of  the  after  treatment  of  the  fore,  the  pub- 
lication itfelf  muft  be  confulted  j  but  for  the  advan*- 
tage  of  thofe  who  may  not  eafily  meet  with  it,  the  fol- 
lowing fhort  account  of  the  operation  is  inferted  in 
Mr,  Park's  own  words. 


Chap.  XLV.         Bones  ai  the  Joints,  519 

"  An  incifion  was  made,  beginning  about  two  in- 
ches above  the  upper  end  of  the  patella,  and  continu- 
ed about  as  far  below  its  under  extremity  :  another, 
croffing  this  at  right  angles,  immediately  above  the 
patella,  the  leg  being  in  an  extended  ftate,  was  made 
through  the  tendons  of  the  extenfor  mufcles  down  to 
the  bone,  and  nearly  half  round  the  limb ;  and  the 
lower  angles  formed  by  thefe  incifions  were  raifed  fo 
as  to  lay  bare  the  capfular  ligament :  the  patella  was 
then  taken  out,  and  the  upper  angles  were  raifed,  fo 
as  fairly  to  denude  the  head  of  the  femur,  and  to  en- 
able me  to  pafs  a  fmall  catling  acrofs  the  pofterior  flat 
part  of  the  bone  immediately  above  the  condyles,  tak- 
ing care  to  keep  one  of  the  flat  fides  of  the  point  of 
the  inftrument  quite  clofe  to  the  bone  all  the  way. 
The  catling  being  withdrawn,  an  elaftic  fpatula  was 
introduced  in  its  place,  to  guard  the  foft  parts  while 
the  femur  was  fawing  through  :  which  done,  the  head 
of  the  bone  thus  feparated  was  carefully  diifeded  out : 
the  head  of  the  tibia  was  then  with  eafe  turned  out 
and  fawn  off,  and  as  much  as  pofTible  of  the  capfular 
ligament  diffefted  away,  leaving  only  the  pollerior 
part  covering  the  veffels  ;  which,  on  examining,  I  had 
the  fatisfadion  to  find  had  not  only  efcaped  unhurt, 
but  that  it  was  not  a  very  narrow  efcape  :  they  had 
flill  a  pretty  good  covering,  and  had  been,  through 
the  whole  operation,  far  enough  out  of  the  courfe  of 
the  knife.  It  nmfl  be  confefled,  that  the  appearance 
of  the  wound  was  fomewhat  formidable,  exhibiting  a 
very  large  cavern  with  very  thin  parietes  ;  and  in 
fhort,  there  feemed  Httle  wanting  to  complete  the  am- 
putation :  yet  as  the  limb  below  would  not  be  depriv- 
ed of  any  part  of  its  nourifhment,  and  as  every  heal- 
thy incifed  furface,  as  well  of  bone  as  of  foft  parts, 
has  a  natural  tendency  to  granulate,  I  could  not  fee 
any  room  to  doubt,  that  nature  would  be  able  to  re- 
pair the  breach." 

Mr.  Park  afterwards  informs  us,  that  he  attempted 
to  perform  the  operation  without  making  the  tranf- 


520  Of  removing  Ends  of        Chap,  XLV, 

verfe  incifion  :  but  he  found  it  could  not  be  done  ; 
and  after  fpending  fome  time  in  the  attempt,  it  \vas 
thought  advifable  to  dcfifl:  from  it.  More  than  two 
inches  of  the  femur,  and  rather  more  than  one  inch 
of  the  tibia,  were  removed  ;  which  were  but  juft 
enough  to  admit  of  the  leg  being  brought  into  a  right 
line  with  the  thigh,  the  previous  contradion  of  the 
flexor  mufclcs  being  fuch  as  to  keep  the  two  fawn 
ends  of  bone  in  clofe  contaQ: :  this  produced  a  con- 
fiderable  redundance  of  the  teguments.  To  fupport 
this,  that  it  might  not  fall  inward,  and  to  keep  the 
edges  of  the  incifion  in  appofition  till  they  fliould  ac- 
quire fome  degree  of  firmnefs,  a  few  ftitches  were 
pafled  through  the  fkin  ;  not  merely  along  the  courfe 
of  the  tranfverfe  incifion,  but  upon  that  of  the  longi- 
tudinal cut  that  extended  up  the  thigh.  The  lighteft 
fuperficial  dreflings  only  were  applied,  and  the  limb 
placed  in  a  cafe  of  tin  from  the  ankle  to  the  infertion 
of  the  glutaeus  mufcle. 

Mr.  Park  very  candidly  enumerates  feveral  objecr 
tions  that  may  be  made  to  this  operation  ;  but,  at  the 
fame  time,  he  thinks  that  all  of  them  may  be  obvia- 
ted. There  are  two  however,  which  in  my  opinion, 
will  always  appear  with  force  againfl:  it :  the  firil  is, 
that  where  the  bones  of  large  joints  are  fo  much  dif- 
eafed  as  to  render  it  necelfary  to  remove  them,  the; 
furrounding  foft  parts  are  commonly  fo  much  thick- 
ened, inflamed  or  ulcerated,  as  to  render  any  attempt 
to  fave  them  very  uncertain,  and  much  more  hazard- 
ous than  the  amputation  of  the  limb  :  and  the  fecond 
is,  the  high  degree  of  inflammation  that  commonly 
fucceeds  to  wounds  of  the  larger  joints. 

With  refpe£t  to  the  firfl  of  thefe,  Mr.  Park  himfelf 
wiflies  it  to  be  underftood,  that  it  is  chiefly  in  afi'ec-r 
tions  of  the  joints  produced  by  external  violence,  that 
he  thinks  this  operation  will  be  peculiarly  ufeful ;  and 
with  refpecl  to  the  laft,  he  obferves,  that  the  heads  of 
large  bones  have  been  frequently  fawn  off,  without 
smy  violent  fymptom  taking  place  :  and  as  he  fup- 


Chap.  XLV.         Bones  at  the  yoints.  521 

pofes  this  to  be  owing  to  the  very  free  divifion  of  the 
capfular  ligaments,  which  in  fuch  cafes  mud  always 
happen,  he  thinks  that  the  total  removal  of  this  liga- 
ment, which  he  advifes  in  this  operation,  will  in  a 
great  meafure  prevent  it.  I  have  obferved  above,  that 
experience  alone  can  determine  upon  the  merits  of 
this  operation  ;  but  I  cannot  avoid  remarking,  that 
no  neceflity  appears  for  the  removal  of  any  part  of 
the  capfular  ligament.  It  may  be  highly  proper  to 
make  the  opening  into  it  free  and  large  ;  but  to  re- 
move it,  by  diflecling  it  off  from  the  contiguous  parts, 
mud  probably  add  to  the  rilk  of  the  operation,  by 
rendering  the  inflammation  more  fevere  than  it  other- 
wife  might  be  ;  at  the  fame  time  that  it  mufl  necelfa- 
rily  render  it  much  more  painful  as  well  as  more  te- 
dious. Farther  experience  may  perhaps,  fet  this  in  a 
different  point  of  view  :  but  at  prefent  I  fee  no  more 
reafon  for  removing  any  part  of  the  capfular  ligament 
in  this  operation,  than  for  the  removal  of  the  tunica 
vaginalis  teftis  in  the  operation  for  the  hydrocele  ;  a 
pradice  now  altogether  laid  afide,  even  where  the 
cyft  is  much  thickened. 


522  Of  If  lies.  Chap.  XLVL 


CHAPTER     XLVL 


OF   ISSUES. 


ISSUES  are  fmall  artificial  ulcers  that  we  form  in 
different  parts  of  the  body,  for  the  purpofe  of  pro- 
curing a  difcharge  of  purulent  matter. 

As  I  have  elfevvhere  treated  fully  of  the  advantages 
that  may  be  derived  from  iffues,  and  of  the  manner  in 
which  they  feem  to  a6b  in  the  cure  of  difeafes,  it  is.not 
at  prefent  neceffary  to  enter  minutely  upon  this  part 
of  the  fubjeft  :  I  fhall,  therefore,  only  obferve,  in  gen- 
eral, that  I  am  daily  more  and  more  convinced  of  the 
utihty  of  iffues  in  the  cure  of  long  continued  fores,  of 
whatever  kind  they  may  be ;  and  that  I  am  ftill  of 
the  opinion  that  they  ad  folely  by  difcharging  a  cer- 
tain quantity  of  the  ferous  parts  of  the  blood  j  and 
not  that  they  ferve  merely  as  drains  for  noxious  hu- 
mours, which,  till  of  late,  has  been  the  prevailing 
opinion  of  practitioners.* 

Among  other  errors  in  practice  to  which  this  opin- 
ion gave  rife,  the  choice  of  fituation  for  iffues  was 
none  of  the  leaft  remarkable.  As  it  was  imagined  that 
ulcers  as  well  as  other  local  difeafes  were  produced  by 
a  determination  of  morbific  humour  to  a  particular 
fpot,  when  iffues  were  advifed,  it  was  confidered  as 
neceffary  to  place  them  as  contiguous  to  the  affefted 
part  as  pollible,  and  always  on  the  fuperior  part  of  the 
limb  when  the  difeafe  was  feated  on  any  of  the  ex- 
tremities, in  order  to  prevent  the  morbid  matter  from 
falling  down  to  it.  But  as  we  now  conclude  that  if- 
fues prove  ufeful  or  other  wife  merely  by  the  quantity 

•  Sec  Chapter  TV.  on  the  Theory  and  Management  of  Ulcers,  where 
ihii  fubject  is  fully  confiderctL 


Chap.  XL VI.  Of  JJfues.  523 

of  matter  which  they  afford,  it  appears  to  be  of  little 
importance  where  they  are  placed ;  and  accordingly 
they  may  be  inferted  wherever  the  patient  thinks  they 
will  occafion  the  lead  inconvenience. 

Some  general  rules,  however,  fhould  be  obferved  in 
the  introduftion  of  iffues  :  they  fhould  never  be  plac- 
ed immediately  above  a  bone  thinly  covered  ;  nor  di- 
rectly above  a  tendon  ;  nor  very  contiguous  to  a  large 
blood  veflel  or  nerve  ;  nor  upon  the  belly  of  a  muf- 
cle.  The  befl:  fituation  for  iffues  is  that  fpace  which 
lies  between  the  tendons  on  th^  back  part  of  the  neck, 
where  there  is  a  confiderable  depth  of  cellular  fub- 
ftance  ;  the  middle  of  the  humerus,  near  to  the  in- 
fertion  of  the  deltoid  mufcle  ;  and  a  confiderable  hol- 
low above  the  flexor  tendon  on  the  infide  of  each 
knee.  They  may  likewife  be  inferted  between  two  of 
the  ribs,  and  on  each  fide  of  the  vertebras  of  the  back  ; 
or,  in  fhort,  wherever  there  is  a  fufficient  quantity  of 
cellular  fubflance  for  the  prote£tion  of  the  parts  be- 
neath. It  is  proper,  however,  to  remark,  that  the  fpot 
ufually  fixed  upon  for  iffues  is  perhaps  the  moft  im- 
proper of  any,  I  mean  diredly  below  the  knee  ;  where 
there  is  never  much  cellular  fubftance ;  where  the 
veins  of  the  leg  can  fcarcely  be  avoided  ;  and  where 
the  peas  are  apt  to  hurt  the  contiguous  tendons. 

Iffues  may  be  formed  in  various  ways  :  by  corrod- 
ing or  removing  the  fl^in  with  epifpaftic  applications ; 
by  making  an  incifion  with  a  fcalpel  or  lancet  ;  by  the 
application  of  cauftic  ;  and  the  introduction  of  a  cord. 

When  an  iffue  is  to  be  opened  by  removing  a  por- 
tion of  fkin,  a  blifter  muff  be  applied  upon  the  fpot, 
exa£tly  of  the  fize  of  the  intended  fore  ;  and  on  the 
blifter  being  removed,  a  difcharge  of  matter  may  be 
kept  up,  by  dreffing  the  part  daily  with  any  common 
ointment  in  which  there  is  mixed  a  fmall  proportion 
of  cantharides  in  fine  powder  :  or,  it  fometimes  proves 
fufficient  to  ufe  this  irritating  application,  and  a  mild 
ointment  of  wajc  and  oil  alternately. 


524  Of  Jfue.^,  Chap.  XL VI. 

In  forming  an  IlTue  by  incifion,  or  with  caufUc,  an 
opening  mufl  be  made  of  fuch  a  fize  as  is  fufficient 
for  affording  a  proper  quantity  of  matter ;  and  the 
aperture  mufl  be  preferred  by  inferting  daily  into  it 
fome  extraneous  body  covered  with  any  mild  digeftive 
ointment,  fuch  as  bafilicon  or  linimentum  arcasi,  while 
the  whole  mufl  be  fecured  with  a  proper  bandage. 
Peas  are  commonly  employed  for  this  purpofe.  Kid- 
ney beans  anfwer  very  well ;  and  fome  make  ufe  of 
gentian  root,  and  of  aurantia  curaflaventia,  ufually 
termed  orange  peas,  turned  into  a  proper  form.  When 
the  opening  is  made  by  an  incifion,  the  fkin  fhould  be 
fupported  on  one  fide  by  an  afliilant,  and  on  the  oth- 
er by  the  left  hand  of  the  furgeon  ;  who  fhould  now, 
wdth  a  fcalpel  in  the  other,  make  a  cut  of  a  fufficient 
length  and  depth  for  receiving  the  number  of  peas  in- 
tended to  be  put  into  it,  and  thus  the  operation  is  fin- 
ifned  :  but  when  done  with  cauflic,  more  attention  i$ 
requifite.  Many  compofitions  of  cauflic  pafle  have 
been  recommended  ;  but  I  have  met  with  none  that  for 
this  purpofe  anfwers  fo  well  as  the  lapis  infernahs  or 
cauflicum  commune  of  different  Difpenfatories.  It 
fhould  be  firfl  reduced  to  powder,  and  made  into  a 
pafle  with  water,  or  with  foft  foap,  when  as  much  of 
it  fhould  be  applied  upon  the  fpot  where  the  iffue  is 
wanted  as  will  make  an  opening  of  a  proper  fize ;  but 
as  it  is  apt  to  fpread  to  the  contiguous  parts,  fome  care 
i^  required  to  prevent  it.  For  this  purpofe,  a  piece  of 
leather  fpread  with  Burgundy  pitch,  or  any  adhefive 
plafler,  with  a  fmall  hole  cut  in  the  centre,  fhould  be 
placed  upon  the  part,  with  the  hole  direclly  on  the 
fpot  where  the  cauftic  is  meant  to  be  applied.  The 
fmall  fpot  thus  left  uncovered,  mull  now  be  fpread 
with  the  cauflic  pafle  ;  and  over  the  whole  there 
Ihould  be  laid  another  piece  of  leather  fpi-ead  with  the 
fame  adhefive  plafler,  fo  that  no  part  of  the  cauflic 
may  efcape.  In  the  courfe  of  ten  or  twelve  hours,  the 
whole  may  be  removed  ;  for  before  this  if  the  cauflic 


Chap.  XL VI.  Of  TJues,  s^S 

is  good,  it  will  have  produced  an  efchar  of  a  fufficient 
depth.  In  the  fpace  of  three  or  four  days,  the  efchar 
will  feparate  from  the  contiguous  found  parts,  when 
the  opening  formed  by  it  muft  be  filled  with  peas  or 
fome  other  of  the  fubf lances  I  have  mentioned. 

When  it  is  neceffary  to  difcharge  a  large  quantity 
of  matter  by  an  iflue,  and  efpecially  when  we  wilh  to 
have  it  from  deep  feated  parts,  we  do  it  by  the  intro- 
duflion  of  a  cord  of  cotton  or  filk,  forming  what  is 
commonly  termed  a  feton.  This  we  often  employ 
with  advantage  in  deep  feated  pains,  particularly  in 
pains  of  the  bread  and  fides  in  phthifis  pulmonalis. 
In  fuch  cafes  it  is  commonly  inferted  between  two  of 
the  ribs  ;  and  it  anfwers  better  in  the  diredion  of  the 
ribs  than  when  placed  acrofs  them,  as  is  fometimes 
done.  A  cord  is  alfo  a  frequent  remedy  in  difeafes 
of  the  head,  particularly  in  ophthalmia  and  other  af- 
fedions  of  the  eyes  ;  and  in  fuch  cafes  it  is  ufually 
placed  in  the  back  part  of  the  neck. 

In  the  introduction  of  a  cord,  the  parts  at  which  it 
is  to  enter  and  pafs  out,  fliould  be  previoufly  marked 
with  ink ;  and  the  cotton  or  filk  being  put  into  the 
eye  of  the  flat  needle,  Plate  LIV.  fig.  5.  and  the  parts 
fupported  by  an  alTiftant,  the  needle  fhould  now  be 
pulhed  in  at  one  of  the  fpots  and  carried  out  at  the 
other,  along  with  two  or  three  inches  of  the  cord, 
which  fhould  be  left  hanging  out.  The  irritation 
which  the  cord  excites  is  foon  followed  by  a  plentiful 
difcharge  of  matter,  which  may  be  increafed  or  dimin- 
iflied  at  pleafure,  by  covering  the  cord  daily,  before 
it  is  dra^n,  with  a  mild  or  an  irritating  ointment. 

In  former  tiuies,  it  was  a  frequent  practice  to  form 
iflues  hf  burning  the  parts  into  which  they  were  to 
be  introduced  with  the  adual  cautery ;  and  in  fome 
parts  or  Europe  it  is  flill  continued  :  but  as  it  is  much 
more  terrifying  than  any  of  thofe  that  I  have  mention- 
ed, andas  it  does  not  appear  to  be  attended  with  any 
particulir  advantage,  it  is  now  in  general  laid  afidc* 


526  Of  IJues.  Chap.  XLVL 

In  China,  Japan,  and  fome  other  eaftern  countries^ 
it  is  ftill  a  prevailing  pradtice,  in  deep  feated  pains,  to 
burn  the  parts  affe£led  down  to  the  bone  with  moxa. 
Moxa  is  a  Hght,  foft  combuftible  down,  of  a  particu- 
lar plant.  A  fmall  cone  of  it  being  wrapped  up,  the 
bafe  of  the  cone  is  fixed  upon  the  part  with  glue  or 
mucilage ;  and  fire  being  put  to  the  oppofite  end  of 
it,  it  is  allowed  to  remain  till  the  whole  is  confumed ; 
and  if  one  appUcation  does  not  prove  fufficient,  it  is 
repeated  once  and  again  as  long  as  it  is  neceflary.  The 
operation  may  be  done  equally  well  with  fine  flax  ; 
but  although  it  has  been  fometimes  done  in  different 
parts  of  Europe,  it  will  not  probably  be  ever  general- 
ly praftifed.  I  have  known  it,  however,  remove  the 
mod  obftinate  fciatic  pains,  where  every  other  reme- 
dy had  failed. 


Chap.  XL  VII.         Of  the  Inoculation^  Esfr.  527 

CHAPTER    XLVII. 

OF  THE  INOCULATION  OF  THE  SMALLPOX. 


THERE  is  caiife  to  imagine,  that  ahnofl:  all  erup- 
tive difeafes,  as  well  as  fome  others,  may  be 
communicated  by  inoculation  :  the  practice,  however, 
is  confined  to  fuch  as  are  not  apt  to  return ;  for  no 
advantage  would  arife  from  inducing  difeafes  to  which 
the  fyftem  might  afterwards  be  liable.  The  plague 
has  been  communicated  by  inoculation  ;  but  in  this 
country  the  fmallpox,  and  of  late  the  cow  pox,  are 
the  only  difeafes  that  we  are  accuftomed  to  inoculate. 
Some  trials  have  indeed  been  made  for  inoculating 
the  meafles  ;  but  as  yet  they  have  not  fucceeded. 

From  the  refult  of  fome  experiments,  there  is  rea- 
fon  to  think,  that  no  difeafe  can  be  communicated 
by  inoculating  with  the  blood  of  an  infeded  perfon. 
This,  however,  is  not  as  yet  precifely  determined  ;  fo 
that  farther  trials  will  be  necefl'ary  to  afcertain  it.  In 
inoculating  the  fmallpox  and  cow  pox,  we  employ 
the  matter  contained  in  the  puftules. 

The  proper  period  for  inoculating,  the  preparation 
of  the  patient,  and  the  fubfequent  treatment  of  the 
difeafe,  are  points  that  more  particularly  fall  to  the 
confideration  of  the  phyfician.  The  mode  of  com- 
municating the  infection  is  our  only  objed  at  prefent. 

In  the  more  early  pradice  of  inoculation,  it  was 
cuftomary  to  tie  an  inieded  thread  round  the  arm  or 
leg ;  to  rub  a  little  variolous  matter  upon  any  part  of 
the  body  ;  or  to  infert  a  piece  of  thread  foaked  in 
matter  beneath  the  cuticle,  with  a  fmall  needle,  and 
to  allow  it  to  remain  till  there  was  reafon  to  think 
that  the  infedion  had  taken  place.     In  any  of  thefe 


525  Of  the  Inoculation        Chap.  XLVlt. 

ways  the  difeafe  may  be  communicated  :  but  as  by 
fome  of  them  there  is  caufe  to  fufped  that  a  variolous 
atmofphere  may  be  produced,  and  that  the  difeafe 
may  be  thus  induced  in  the  fame  way  as  in  the  cafe  of 
a  common  contagion,  and  confequently  that  fome  of 
the  advantages  of  inoculation  may  not  be  obtained 
from  them,  thefe  modes  of  giving  the  fmallpox  ought 
therefore  to  be  laid  afide. 

Till  of  late,  inoculation  was  commonly  performed 
by  making  an  incifion  of  about  half  an  inch  in  length 
through  the  fkin  to  the  depth  of  the  cellular  fubftance  : 
a  bit  of  thread  impregnated  with  variolous  matter  was 
then  inferted,  and  retained  for  two  or  three  days  with 
a  comprefs  and  bandage.  To  this  praftice,  however, 
the  great  unneceflary  pain  attending  it,  and  the  apt- 
nefs  of  the  wound  to  deeenerate  into  a  dil'aoreeable 
ulcer,  are  ftrong  objedions. 

The  prefent  mode  of  inferting  the  matter  appears 
to  be  in  every  refpedl  more  eligible.  The  point  of  a 
lancet,  previoufly  covered  with  variolous  or  vaccine 
matter,  is  infmuated  through  the  cuticle  fo  as  to  fcratch 
or  nightly  injure  the  cutis  vera.  It  might  frequently 
indeed  be  fufficient  to  pafs  it  through  the  cuticle  on- 
ly ;  but  we  do  not  fo  readily  fail  when  a  fmall  parti- 
cle of  blood  follows  the  lancet.  When  the  matter  is 
recently  taken  in  an  early  period  of  the  difeafe,  the 
lancet  may  be  introduced  without  being  moiftened ; 
but  whenever  the  matter  has  become  firm  and  hard, 
it  fhould  be  rendered  foft  with  a  drop  of  warm  water, 
or  by  holding  it  in  warm  fteam. 

The  operation  may  be  done  in  any  part  of  the  bo- 
dv  ;  but  the  arm  is  generally  preferred.  One  fcratch 
would  for  the  mofl  part  prove  fufficient ;  but  with  a 
view  to  enfure  fuccefs,  two  or  even  three  are  com- 
monly made  at  the  dillance  of  an  inch  from. each  oth- 
er. It  is  to  be  obferved,  however,  that  when  the  mat- 
ter takes  effe6t  in  all  the  fcratches,  the  inflammation 
that  enfues  being  communicated  from  one  to  the  oth- 


Chap.  XLVII.         vfthe  Smallpox.  529 

er,  is  often  confiderable,  and  gives  much  pain  and  un- 
eafinefs.  This  is  eafily  prevented  by  making  only 
one  fcratch  in  each  arm,  which  for  fcveral  years  paft 
I  have  uniformly  done. 

In  this  method  of  inoculating,  we  never  employ 
either  bandage  or  comprefs  ;  for  the  wound  is  fo  tri- 
fling that  no  kind  of  dreffing  is  neceflary  :  fo  that  we 
readily  fee,  at  the  end  of  a  few  days,  whether  the  in- 
fe£lion  will  take  place  or  not ;  for  in  general,  by  the 
third  or  fourth  day,  if  the  operation  is  to  fucceed,  the 
fcratches  made  with  the  lancet  become  red,  fwelled, 
and  fomewhat  painful. 


Vol.  III.  L  1 


530  Of  dimlniJJjing  Pain      Chap.  XLVIII. 


CHAPTER    XLVIII. 


OF  PREVENTING  OR  DIMINISHING  PAIN  IN  CHIRUR- 
GICAL.    OPERATIONS. 


TO  be  able  to  alleviate  the  mifery  of  thofe  who 
are  obliged  to  fubmit  to  dangerous  operations, 
muft  afford  the  higheft  gratification  to  every  practi- 
tioner :  and  as  pain  is  the  mod  dreadful  part  of  every 
operation,  it  necelfarily  demands  our  mod  ferious  at- 
tention. 

The  pain  induced  by  operations  may  be  leffened  in 
different  ways :  by  diminifliing  the  fenfibility  of  the 
fyftem  ;  and  by  comprefling  the  nerves  that  fupply  the 
parts  upon  which  the  operation  is  to  be  performed. 

Narcotics  of  every  kind  might  be  employed  for  the 
purpofe  of  leffening  general  fenfibility ;  but  nothing 
anfwers  this  with  fuch  certainty  and  effe£t  as  opium* 

But  as  opiates,  when  given  in  dofes  large  enough 
for  this  purpofe,  are  apt  to  induce  ficknefs  and  vom- 
iting, I  feldom  venture  on  giving  them  before  an  op- 
eration, unlefs  the  patient  has  previoufly  been  in  the 
habit  of  ufmg  them.  In  general  they  prove  moft  ufe- 
ful  when  given  immediately  after,  when  they  very 
commonly  alleviate  that  pungent  forenefs  of  which  pa- 
tients at  this  time  ufually  complain  ;  and  by  continu- 
ing to  give  them  in  adequate  dofes  from  time  to  time, 
we  are  often  enabled  to  keep  the  patient  eafy,  till  re- 
lief is  obtained  by  the  formation  of  matter,  or  by  the 
removal  of  that  inflammatory  tenfion  that  ufually  takes 
place  after  every  capital  operation  :  and  as  this  proves 


Chap.  XLVIII.     171  Chirurgical  Operations.  531 

not  only  highly  comfortable  to  the  patient,  but  tends 
in  the  moll  etlVdual  manner  to  moderate  the  febrile 
fymptoms  that  commonly  occur,  it  (liould  never  be 
omitted. 

It  has  long  been  known,  that  the  fenfibility  of  any 
part  may  not  only  be  leffened,  but  even  altogether  fuf- 
pended,  by  comprefling  the  nerves  that  fupply  it :  and 
accordingly,  in  amputating  limbs,  patients  frequent- 
ly defire  the  tourniquet  to  be  firmly  fcrewed,  from  find* 
ing  that  it  tends  to  diminilh  the  pain  of  the  operation. 

The  eifed:  of  this,  however,  being  inconfiderable, 
it  has  lately  been  propofed  by  Mr.  James  Moore,  of 
London,  to  comprefs  the  principal  nerves  fo  com- 
pletely as  to  render  the  parts  beneath  altogether  in- 
feiifible.  In  Plate  XCIX.  an  inftrument  is  delineat- 
ed, by  which  this  may  be  very  effedually  done. 

'Whether  or  not  it  will  anfwer  with  eafe  and  cer- 
tainty, experience  alone  muft  determine  :  but,  in  the 
mean  time,  we  are  much  indebted  to  the  ingenious 
author,  for  affording  a  hint  that  eventually  may  tend 
to  mitigate  the  fufierings  of  thofe  whom  neceflity 
obliges  to  fubmit  to  chirurgical  operations.  All  that 
this  inftrument  feems  to  require  in  order  to  render  it 
perfed,  is  the  power  of  comprefTmg  the  nerves  of  a 
limb  without  affeding  the  veins ;  for  as  it  is  found 
that  the  nerves  muft  be  compreffed  for  a  confiderable 
time,  at  leaft  an  hour,  before  the  parts  beneath  are 
rendered  altogether  infenfible,  the  veins  could  not  be 
compreffed  for  fuch  a  length  of  time  but  with  the  rifk 
of  burfling.  With  a  view  to  prevent  fuch  a  difagree- 
able  occurrence,  Mr.  Moore  propofes  that  one  of  the 
veins  in  the  limb  fhould  be  opened.  But  as  this  might 
prove  hurtful  to  weakly  patients,  in  whom  it  is  often 
of  importance  to  guard  againft  the  lofs  of  blood,  it 
would  be  better  to  avoid  it,  by  having  the  inftrument 
formed  in  fuch  a  manner,  that  it  might  comprefs  the 
principal  nerves  only,  without  materially  affe6ting  the 
L  h  2 


$^2  Ofdimimjhing  Pain,  isfc.     Chap.  XL VIII. 

veins.  This  will  not  indeed  be  eafily  done,  as  the 
nerves  ufually  run  at  no  great  diflance  from  the  veins : 
but  the  fame  purpofe  may  perhaps  be  anfwered  by 
comprefling  the  arteries  of  the  Hmb  for  a  minute  or 
two  before  any  preifure  is  appHed  to  the  veins  j  by 
which  the  latter  may  be  previoufly  emptied. 


I 


Sea.  I.  Of  MJdwifery.  533 


CHAPTER    XLIX. 

OF   MIDWIFERY. 

SECTION     I. 

General  Ohfervations  on  Midwifery, 

MIDWIFERY  being  now  confidered  as  a  diftind 
branch  of  chirurgical  pra«5lice,  a  minute  ac- 
count of  it  will  not  be  expected  in  a  Syftem  of  Sur- 
gery. For  more  particular  information,  thofe  authors 
who  have  written  upon  it  may  be  confulted  :  but  I 
have  judged  it  proper  to  delineate  the  inftruments  ufu- 
ally  employed  in  midwifery ;  and  to  defcribe  two  op- 
erations, which,  although  immediately  conneded  with 
this  branch,  are  yet  more  frequently  performed  by  the 
furgeon  than  the  accoucheur ;  namely,  the  Casfarean 
operation,  and  the  divifion  of  the  fymphyfis  pubis. 

A  great  variety  of  inftruments  have  been  invented 
by  practitioners  in  midwifery  ;  almoft  eveiy  publica- 
tion, indeed,  upon  this  fubjed,  announces  fome  new 
invention.  It  is  only  thofe  inftruments,  however, 
which  experience  has  fhown  to  .be  ufeful,  that  I  mean 
to  defcribe  :  they  are  not  numerous  ;  and  are  all  de- 
lineated in  Plates  CII.  CIII.  CIV.  CV.  and  CVI. 

With  the  forceps  in  Plate  CII.  fig.  2.  we  lay  hold 
of  the  head  of  the  child  when  the  mother  is  much  en- 
feebled and  th^  contradlion  of  the  uterus  not  fufficient 
to  expel  the  child  in  the  ufual  way :  and  when  deliv- 
ery cannot  be  effedled  even  in  this  manner,  or  by  turli- 
ing  the  child,  and  bringing  it  away  by  the  feet,  as 
fometimes  happens  from  the  pelvis  being  much  dif- 
torted,  we  employ  the  crotchet  reprefented  in  Plate 


534.  Of  Mld'wlfery.  Chap.  XLIX, 

cm.  fig.  3.  for  bringing  the  child  away  piecemeal,  af- 
ter leffening  the  fize  of  the  head  by  an  opening  made 
in  the  fkull  for  difcharging  the  brain  with  the  fciifars 
reprefented  in  fig.  i .  of  the  fame  Plate. 

The  neceffity,  however,  of  iifing  any  of  thefe  in- 
ftruments  I  believe  to  be  exceeding  rare  :  they  are  in- 
deed frequently  employed  ;  but  this  proceeds  in  a 
great  meafure  from  impatience  on  the  part  of  prafti- 
tioners,  who  often  force  the  delivery  of  the  child,  when 
nature,  if  left  to  herfelf,  would  eft'eft  it  in  a  much  more 
eafy  manner.  This  fad  is  fo  certainly  well  founded, 
and  is  of  fuch  general  importance,  that  practitioners 
of  every  defcription,  and  more  efpecially  thofe  who  are 
newly  entering  on  bufmefs,  fhould  never  lofe  fight  of 
it.  By  not  meeting  with  that  attention  which  it  me- 
rits, both  the  forceps  and  crotchet  are  daily  employed 
with  too  much  freedom,  to  the  difgrace  of  the  art,  and 
often  with  irreparable  injury  both  to  the  mother  and 
child. 

In  fome  cafes  it  happens,  that  delivery  cannot  be 
accomplifhed  even  with  the  afliftance  of  thefe  inftru- 
ments,  owing  to  the  brim  of  the  pelvis  being  fo  nar- 
row that  it  will  not  allow  any  part  of  the  child  to  pafs. 
In  fuch  circumftances,  the  Caefarean  fedlion,  as  it  is 
termed,  ufed  formerly  to  be  pra(3:ifed  ;  but  the  dan- 
ger attending  that  operation  being  fo  great  that  the 
mother  was  feldom  faved  by  it,  Mr.  Sigault  of  Paris, 
about  four  and  twenty  years  ago,  propofed  the  divi- 
fion  of  the  fymphyfis  pubis,  for  the  purpofe  of  increaf- 
ing  the  diameter  of  the  pelvis,  and  for  extracting  the 
child  in  the  ufual  way,  by  the  vagina. 


Se£l.  II.         Of  the  Cxfarean  Operation,  535 

SECTION    II. 

Of  the  Cafarean  Operation. 

THIS  operation  may  become  neceflary,  as  we  have 
feen  in  the  lafl  fe6lion,  by  the  brim  of  the  pelvis 
being  fo  narrow  that  it  will  not  allow  the  child  to  pafs  j 
and  it  may  alfo  become  proper  where  the  child  has 
been  forced  into  the  cavity  of  the  abdomen  by  a  rup- 
ture in  the  uterus,  as  fometimes  happens  from  the  ute- 
rus contrading  with  too  much  force  before  the  os  tin* 
cse  is  fufficiently  dilated. 

The  Cccfarean  feftion  may  be  performed,  either  with 
a  view  to  fave  both  the  mother  and  child,  when  the 
child  cannot  be  extraAed  in  any  other  manner  ;  to  fave 
the  mother  only  when  we  know  that  the  child  is  dead  ; 
or  to  fave  the  child  immediately  after  the  death  of  the 
mother. 

As  there  are  few  inftanees  of  the  mother  being  fav- 
ed  by  this  operation,  feme  have  advifed  that  it  {hould 
never  be  performed  till  after  the  death  of  the  mother, 
I  am  clearly  of  opinion,  that  an  operation  attended 
with  fo  much  hazard,  fliould  never  be  advifed  as  long 
as  there  is  the  leafl  reafon  to  hope  that  delivery  may 
be  effedled  in  any  other  manner  :  but  I  alfo  think,  that 
it  is  the  duty  of  every  practitioner  to  propofe  it  when 
this  cannot  be  accomplilhed  ;  for  it  is  furely  better  to 
afford  the  fmall  chance  to  the  mother  that  accrues 
from  it,  than  to  leave  her  with  the  certain  profpeft  of 
death  ;  while  by  the  fame  means  we  may  be  enabled 
to  fave  the  child,  which  otherwife  would  be  deftroy- 
ed.  None  will  hcfitate  in  advifmg  it  after  the  death 
of  the  mother,  when  the  child  is  found  to  be  living. 
The  following  is  the  method  of  performing  it. 

The  patient  fhould  be  placed  upon  a  table  of  the 
ufual  height,  and  laid  upon  her  back  j  her  ha^ds  and 


53^  Of  the  Cafarean  Opcraticn.     Chap.  XLIX. 

legs  being  properly  fecured  by  affiftants  ;  her  head 
fhould  be  moderately  elevated  with  pillows,  and  her 
thighs  fomewhat  railed,  in  order  to  relax  the  abdomi- 
nal mufcles.  The  operator  (landing  on  one  fide  of 
the  table,  is,  with  a  common  round  edged  fcalpel,  to 
make  an  incifion,  fix  inches  in  length,  through  the 
fkin  and  cellular  fiibftance,  on  one  fide  of  the  abdo- 
men :  the  cut  fhould  commence  two  inches  above  the 
umbilicus  on  the  outer  edge  of  the  rectus  mufcle,  and 
from  thence  fliould  be  carried  in  a  peipendicular  dl- 
redlon  fix  inches  downwards.  The  uterus  is  now  to 
be  laid  bare,  by  carrying  the  incifion  through  the  ten- 
dinous parts  of  the  abdominal  mufcles,  and  peritonae- 
um J  and  this  being  done,  an  opening  of  the  fame 
length  mufl  be  made  in  the  uterus  itfelf.  The  eafieft 
method  of  effecting  this,  is,  to  make  a  fmall  opening 
with  the  fcalpel,  fufficient  to  admit  the  finger,  to  ferve 
as  a  conductor  to  a  probe  pointed  bifloury,  w'ith  which 
the  remaining  part  of  the  incifion  Ihould  be  finifhed. 
I  may  alfo  remark,  that  the  bifloury  inferted  upon  the 
finger,  at  an  opening  made  for  the  purpofe,  affords 
the  eafiefl  method  of  dividing  the  peritonseum  and 
tendinous  aponeurofis  of  the  abdominal  mufcles. 

If  any  large  blood  veffel  is  cut  either  in  making  the 
outward  incifion  or  in  dividing  the  uterus,  it  fhould 
be  immediately  tied  with,  a  ligature  of  a  fuflicient 
length  to  hang  out  at  the  wound.  The  child  mufl 
now  be  taken  out ;  the  placenta,  and  any  effufed  blood 
^hat  may  have  efcaped  during  the  operation,  being  al- 
fo removed,  and  the  inteflines,  if  they  have  protrud- 
ed, being  replaced,  the  external  opening  fliould  be 
fecured  with  three  or  four  futures,  in  the  manner  I 
have  advifed  in  Chapter  III,  Sed.  XII.  §  3, 

The  wound  being  covered  with  a  pledget  of  any 
emollient  ointment,  the  abdomen  fliould  be  fupported 
with  feveral  turns  of  a  broad  flannel  roller  ;  when  the 
patient  fhould  be  carried  to  bed,  and  flriclly  enjoined 
to  avoid  fpeaking  and  every  kind  of  exertion. 


Sed.  II.         Of  the  Cafarian  Operation.  537 

Various  caufes  concur  to  render  this  a  very  danger- 
ous operation  :  of  thefe,  the  extenfive  expofure  of  the 
abdominal  vifcera,  and  hemorrhagies  from  the  uterus, 
are  the  mod  material.  Any  protrufion,  therefore, 
which  occurs  of  the  bowels,  fhould  be  immediately 
replaced,  and  no  veiTel  of  any  importance  that  may  be 
cut  in  the  divifion  of  the  uterus  fliould  be  left  untied  : 
this  is  not  adviied  by  writers  upon  this  fubjeft,  but  I 
fee  no  harm  that  can  enfue  from  it.  If  the  ligatures 
are  applied  with  the  tenaculum,  they  will  foon  fepa- 
rate  ;  and  by  hanging  out  at  the  external  wound,  they 
may  at  any  time  be  pulled  away.  It  may  be  remark- 
ed, that  it  is  internal  hemorrhagies  only  that  we  have 
to  dread,  I  mean  fuch  as  occur  from  the  veffels  of  the 
uterus  :  for,  by  carrying  the  incifion  on  the  outer 
edge  of  the  retflus  mufcle,  we  avoid  the  epigaftric  ar- 
tery, the  only  veffel  of  importance  that  runs  any  rilk 
of  being  hurt  in  the  divifion  of  the  teguments  and 
mufcles. 

In  order  to  avoid  the  rifk  of  hemorrhagies  from  the 
uterus,  fome  have  advifed  the  incifion  never  to  be 
made  at  that  part  where  the  placenta  adheres  ;  while, 
by  others,  we  arc  directed  to  make  the  opening  into 
the  uterus  exadly  in  a  longitudinal  direftion,  by 
which  we  are  told  that  the  principal  veffels  with  which 
it  is  fupplied  will  mod  readily  be  avoided.  No  ad- 
vantage, however,  is  derived  from  this  :  for  the  inci- 
fion in  the  uterus  mufl  correfpond  exactly  with  the 
external  incifion  ;  which  cannot  with  propriety  be 
made  in  any  other  diredion  than  the  one  I  have  men- 
tioned. Befides,  it  would  often  be  impofTible  to  dif- 
tinguifli  the  part  at  which  the  placenta  adheres  ;  nor 
is  there  much  ground  to  fuppofe  that  the  hemorrhagy 
from  the  uterus  depends  fo  much  upon  the  diredion 
as  on  the  extent  of  the  incifion ;  and  it  ought  not  to 
be  lefs  than  fix  inches  in  length,  as  the  child  could 
not  be  extracted  with  freedom  at  a  fir.alier  opening. 
It  is  fcarcely  ncceiVary  to  remark,  that  the  child  and 
placenta  fhould  be  removed  as  foon  after  the  incifion 


538  Of  the  Divifton  of  Chap.  XLIX. 

is  made  in  the  uterus  as  poflible.  It  is  thus  allowed 
to  contraft,  which  it  does  inftantaneoufly  with  great 
force  ;  by  which  the  hemorrhagy  is  more  readily 
flopped  than  by  any  means  that  we  could  employ 
for  it. 

By  others,  we  are  advifed  to  leave  a  large  opening 
at  the  under  part  of  the  external  incifion,  in  order  to 
give  vent  to  any  effufion  of  blopd  that  may  happen. 
No  advantage,  however,  is  gained  by  this,  as  the  in- 
cifion in  the  uterus,  although  oppofite  to  the  external 
opening  at  firft,  very  foon  falls  beneath  it  when  it  con- 
tra£ls  ;  by  which  any  blood  that  is  difcharged  falls 
into  the  bottom  of  the  abdomen  where  it  coagulates, 
and  thus  cannot  be  difcharged  at  the  wound.  And 
as  it  is  of  importance  to  prevent  the  air  as  much  as 
pollible  from  finding  accefs  to  the  abdomen,  the  ex- 
ternal cut  fhould  be  quickly  and  entirely  fliut,  by  as 
many  futures  as  the  length  of  it  requires.  The  moft 
effeftual  method  with  which  I  am  acquainted  of  pre- 
venting hemorrhagies  is,  the  tying  of  any  large  veflels 
in  the  manner  I  have  mentioned  ;  keeping  the  patient 
cool  and  free  from  pain,  by  regulating  the  air  of  the 
apartment  to  a  proper  temperature,  and  adminiftering 
opiates  ;  and  by  preventing,  as  I  have  obferved  above, 
every  kind  of  bodily  exertion.  • 


SECTION    III. 

Of  the  Div'ifi,n  of  the  Symphyfis  Pubis. 

IT  has  been  long  known,  that  the  bones  of  the  fe- 
male pelvis  are  connedled  in  fuch  a  manner,  that 
during  the  latter  months  of  pregnancy,  and  efpecially 
during  labour,  they  are  feparated  in  fome  degree  from 
each  other ;  by  which  the  pall^^ge  of  the  .child  is  ren- 
dered' much  eafier  than  it  otherwife  would  be.  It 
was  a  knowledge  of  this  fa6t,  and  the  great  danger 


Sect.  III.  the  Symphyfu  Pubis.  539 

attending  the  Ca^farean  operation,  that  firft  fuggefted 
the  idea  of  dividing  the  bones  of  the  pubis  at  their 
junction  with  each  other  in  cafes  of  narrow  pelvis.  It 
was  propofed  upwards  of  two  hundred  years  ago,  by 
a  French  furgeon  of  the  name  of  Pineau  ;  but  Mr. 
Sigault  of  Paris  was  the  firfl  who  had  the  merit  of 
putting  it  in  practice,  in  the  year  1777. 

The  operation  is  eafily  performed.  The  patient 
piufl  be  laid  upon  her  back  on  a  table  of  a  conveni- 
ent height ;  the  pelvis  fhould  be  elevated  with  two  or 
three  pillows  put  beneath  it,  and  the  legs  and  arms 
Secured  by  afliftants.  When  in  this  fituation,  the  blad- 
der muft  be  emptied  by  the  introduction  of  a  cathe- 
ter, which  fliould  be  retained  in  the  urethra  by  one 
of  the  afliftants  till  the  divifion  of  the  bones  is  com- 
pleted. 

After  (having  the  pubis,  the  operator,  ftanding  on 
one  fide  of  the  patient,  fliould,  with  a  longitudinal 
incifion,  divide  the  fkin  and  cellular  fubftance  cover- 
ing the  pubes  at  their  fymphyfis  :  the  cut  ought  to 
commence  at  the  upper  edge  of  thefe  bones,  and  be 
continued  nearly,  but  not  entirely,  along  their  whole 
breadth  :  on  the  bones  being  laid  bare,  the  cartilage 
by  which  they  are  joined  muft  be  flowly  and  cautiouf- 
ly  divided  ;  and  as  it  is  by  no  means  hard,  it  is  eafily 
done.  Both  the  teguments  and  cartilage,  may  be  di- 
vided with  a  firm  round  edged  fcalpel  of  the  com- 
mon form,  which  is  the  only  inftrument  except  the 
catheter  that  is  neceifary  in  this  operation.  The  in- 
tention of  the  catheter  is,  to  point  out  the  courfe  of 
the  urethra  to  the  operator ;  for  it  lies  fo  contiguous 
to  the  pubes  at  their  fymphyfis,  as  to  be  in  great  dan- 
ger of  being  cut,  if  this  precaution  is  negleflted  :  even 
the  bladder  itfelf  might  be  injured,  were  the  divifion 
of  the  cartilage  not  conducted  with  caution  :  but  with 
due  attention  to  thefe  points,  and  avoiding  the  total 
divifion  of  the  foft  parts  at  the  under  edge  of  the 
bones,  all  rifl^  of  hurting  either  the  bladder  or  urcr 
Vbra  may  be  prevented. 


540  Of  the  Dhi/ton  of         Chap.  XLIX. 

On  the  dlvifion  of  the  cartilage  being  completed, 
the  bones  recede  confiderably  from  each  other.  To 
prevent  any  confequences  that  might  enfue  from  their 
Separating  forcibly  and  fuddenly,the  affiftants  who  have 
the  charge  of  the  thighs  fhould  be  defired  to  fupport 
them,  particularly  towards  the  end  of  the  operation  ; 
and  if  a  fufficient  opening  is  not  gained  in  this  man- 
ner, the  thighs  may  afterwards  be  flowly  and  gradual- 
ly feparated. 

The  child  is  now  to  be  delivered  in  the  ufual  way 
by  the  vagina  ;  and  this  being  effected,  and  the  pla- 
centa removed,  the  bones  fhould  be  immediately  put 
together,  and  retained  as  exactly  as  poflible  in  their 
fituation,  by  the  proper  application  of  a  flannel  or  cot- 
ton roller  round  the  pelvis  and  thighs ;  at  the  fame 
time  that  the  patient  fhould  be  defired  to  remain  as 
much  as  pofTible  in  one  poflure.  The  fore  does  not 
require  any  particular  attention  :  in  general,  it  heals 
eaiily  with  light  mild  dreflings  ;  and  for  the  mofl  part 
the  union  of  the  bones  is  completed  in  the  courfe  of 
the  fifth  or  fixth  week.  The  patient,  however,  fhould 
not  be  allowed  to  walk,  or  to  put  the  body  into  any 
poflure  that  might  alter  the  fituation  of  the  bones,  till 
nine  or  ten  weeks  have  elapfed. 

The  chief  objeftion  that  occurs  to  this  operation  is, 
the  fmall  fpace  that  is  gained  by  it  in  that  pait  of  the 
pelvis  where  fpace  is  mofl  required.  By  feparating 
the  offa  pubis  at  their  fymphyfis,  thefe  bones  do  in- 
deed recede  to  a  confiderable  diflance  from  each  oth- 
er :  for  the  mofl  part  the  feparation  that  takes  place 
will  be  at  leafl  two  inches  in  length  ;  but  this  does 
not  increafe  the  narrow  diameter  of  the  pelvis,  that  is, 
the  bones  of  the  pubis  will  fliil  remain  at  nearly  the 
fame  diRnnce  from  the  os  facrum  as  before  the  opera- 
tion ;  and  in  almoft  every  inflance  of  difficult  labour 
from  malconformation  of  the  pelvis,  we  find  that  it 
proceeds  entirely  from  the  offa  pubis  and  os  facrum 
being  too  near  each  other.  It  may  often  happen, 
however,  that  th.e  head  of  the  child  may  be  fo  fitua- 


Se6t.  III.  tbi*  Symphyfis  Pubis.  541 

ted,  that  even  this  reparation  of  the  ofia  pubis  alone 
may  allow  it  to  pafs,  when  otherwife  it  would  have 
remained  entirely  above  the  brim  of  the  pelvis ;  and 
as  we  do  not  find  that  the  operation  is  produ6live  of 
much  danger,  for  in  diiicrent  inflances  in  has  been 
done  more  than  once  on  the  fame  perfon,  it  fliould  al- 
ways be  advifed,  when  we  are  convinced  that  the  pel- 
vis is  fo  narrow  that  the  child  cannot  polTibly  pafs 
through  it.  It  fliould  always  be  advifed  in  preference 
to  the  Ca^farean  operation. 

If  farther  experience  (liall  fliow,  that  in  all  cafes  of 
narrow  pelvis,  the  child  may  be  delivered  in  this  man- 
ner, it  fhould  even  be  preferred  to  the  mode  of  deliv- 
ering with  the  crotchet,  which  is  undoubtedly  one  of 
the  moft  barbarous  operations  in  furgery  ;  for  while 
the  very  intention  of  the  operation  is  to  deftroy  the 
child,  it  often  tears  and  mangles  the  mother  fo  much 
that  {he  never  recovers  from  the  eii'edls  of  it. 


54-  Of  Opening  Ghap.-  L.- 


CHATPER     L. 


OF  OPENING  DEAD  BODIES. 


WITH  a  view  to  difcover  the  feat  and  caufes  of 
difeafes,  and  at  the  inftance  of  the  civil  mag- 
iftrat^  in  cafes  of  violent  tleath,  furgeons  are  employ- 
ed to  open  dead  bodies ;  and  to  do  this  with  accura- 
cy, every  preternatural  appearance  fliould  be  commit- 
ted to  paper.  After  noting  any  external  marks  of  dif- 
eafe,  we  proceed  to  examine  the  Hate  of  the  different 
cavities  and  of  their  contents.  ^Vhen  the  difeafe  has 
been  evidently  fcatcd  in  one  cavity,  we  do  not  open, 
the  others ;  but  when  they  are  all  to  be  examined,  it 
is  proper  to  begin  with  the  head. 

The  body  being  placed  upon  a  table  of  a  conve* 
nient  height,  and  the  head  firmly  fixed  by  an  affiflant, 
an  incifion  fiiould  be  made  from  ear  to  ear  acrofs  the 
parietal  bones.  The  fcalp  is  now  to  be  dilTecled  from 
the  parts  beneath  ;  and  one  half  being  turned  back- 
ward and  the  other  over  the  face,  a  common  amputa- 
ting faw  is  ufed  for  dividing  the  cranium  :  the  uivifion 
may  be  begun  on  the  os  frontis  immediately  above  the 
frontal  fniufes,  and  fhouid  afterwards  be  continued 
backward  through  the  parietal  bones  and  os  occipitis. 
The  upper  part  of  the  fkuU  is  now  to  be  raifed  with  a 
levator ;  by  which  the  dura  mater  may  be  freely  ex- 
amined ;  and  if  we  wifli  to  go  to  the  depth  of  the  ven- 
tricles only,  this  may  be  done  without  removing  the 
brain.  But  when  our  objecl  is  to  examine  the  ftate 
of  the  brain  and  cerebellum,  they  muft  both  be  remov- 
ed and  examined  at  leifure.  This  being  done,  and  all 
the  extravafated  blood  taken  off  with  a  fponge,  the 
brain  and  cerebellum,  mull  be  replaced  with  the  fkuU 
cap  above  them.     The  two  portions  of  fcalp  are  now 


Chap.  L.  Dead  Bodies.  543 

to  be  drawn  over  the  whole,  and  fecured  in  their  fit- 
uation  by  fewing  the  edges  of  the  cut  together  from 
one  end  to  the  other,  either  with  the  glover's  flitch, 
or  in  any  other  way  which  the  operator  may  prefer. 
For  this  purpofe  narrow  tape  is  ufually  employed,  and 
a  large  curved  needle  with  a  triangular  point. 

The  cavities  of  the  thorax  and  abdomen  are  mod 
effedually  expofed  in  the  following  manner  :  let  an 
incifion  be  made  through  the  common  teguments  from 
the  top  of  the  fternum  to  the  umbilicus,  and  let  it  be 
continued  on  each  fide  through  the  abdominal  muf- 
cles,  from  the  umbilicus  in  an  oblique  diredion  down 
to  the  top  of  the  os  ileum  :  the  teguments  and  muf- 
cles  muit  now  be  difl'eded  from  the  thorax,  till  all 
the  cartilages  which  conned  the  fternum  and  ribs  are 
freely  laid  bare  ;  and  being  drawn  backward,  the  car- 
tilages mufl  be  divided  v/ith  a  ftrong  knife  as  near  as 
poltible  to  the  ribs ;  when  the  diaphragm  being  fcpa- 
rated  beneath,  the  under  part  of  the  fternum  and  car- 
tilages conneded  with  it,  being  raifed  and  turned  up- 
ward, the  fternum  muft  either  be  feparated  from  the 
clavicles,  or  cut  acrofs  near  to  the  upper  end  of  it.  In 
this  manner  the  contents  of  the  thorax  and  abdomen 
are  brought  into  view,  when  moft  of  them  may  be  ex- 
amined without  being  removed  ;  but  when  more  ac- 
curacy is  required  than  this  admits  of,  the  whole 
(liould  be  taken  out :  or,  when  a  partial  examination 
is  only  required,  that  portion  of  them  only  may  be 
removed  vvhich  we  mean  to  infped. 

To  prevent  the  inconvenience  refulting  from  the 
infufion  of  much  blood  and  excrement,  two  ftronsf 
ligatures  ftiould  be  paiicd  at  the  diftance  of  an  inch 
from  each  other  round  the  under  part  of  the  aliamen- 
tary  canal  and  large  contiguous  blood  vefiels,  and 
round  the  trachea,  oefophagus,  and  large  blood  vcilels 
of  the  neck.  The  parts  between  the  two  ligatures  both 
above  and  below  bcinsx  divided,  the  vvhole  viicera  of 
both  the  cavities  may  then  be  eafily  removed  by  dif- 


544  Q/*  Opoibig  Dead  Bodies.         Chap.  L. 

feding  them  from  the  contiguous  parts,  and  raifmg 
them  up  as  we  go  along. 

The  neceifary  examination  being  finiflied,  the  ef- 
fufed  blood  all  wafhed  off  with  a  fponge,  and  the  vif- 
cera  replaced,  the  teguments  mull  be  drawn  over 
them,  and  flitched  together  with  as  much  ne^itnefs  as 
poffible. 

In  opening  bodies  that  have  died  of  any  difeafe, 
the  operator  fliould  be  as  cautious  as  poffible  in  avoid- 
ing cuts  or  fcratches  of  his  fingers  and  hands  :  vari- 
ous inllances  have  occurred  of  much  diftrefs  being 
induced ;  and  in  fome  cafes  even  death  has  enfued, 
from  inattention  to  this  circumflance. 


Chap.  LI.  Of  Embalming,  545 

CHAPTER    LL 


OF  EMBALMING. 


IN  former  times,  embalming  was  pra£lifed  with  more 
care  and  attention  than  it  is  now.  This  was  a  ne- 
ceHTary  confequence  of  the  defire  which  then  prevail- 
ed, of  preferving  dead  bodies  for  ages.  At  prefent  it 
is  feldom  employed,  except  for  the  purpofe  of  pre- 
venting bodies  from  putrefying,  during  the  fhort  fpace 
which  elapfes  between  the  death  and  burial  of  the  per- 
fon  ;  and  not  even  with  this  view,  if  the  corpfe  be  not 
to  be  kept  longer  than  is  ufually  done  in  private  life. 
The  following  is  the  prefent  method  of  embalming. 
The  brain,  and  all  the  vifcera  of  the  thorax  and  abdo- 
men, being  removed  in  the  manner  I  mentioned  in  the 
laft  Chapter,  they  are  all,  excepting  the  heart,  put  in- 
to a  leaden  box  with  a  confiderable  quantity  of  an  ar- 
omatic antifeptic  powder,  prepared  with  myrrh,  frank- 
incenfe,  cloves,  the  leaves  of  lavender,  rofemary,  mint, 
fage,  and  other  fimilar  articles ;  and  to  thefe  are  add- 
ed a  proportion  of  any  odoriferous  oils.  The  blood 
being  removed  from  the  different  cavities,  and  the 
heart  replaced,  they  are  all  filled  with  the  fame  kind 
of  powder,  with  a  due  proportion  of  odoriferous  oils 
or  fpirits,  and  the  parts  afterwards  fewed  up  in  the 
manner  I  have  already  advifed.  By  fome,  too,  the 
mouth  and  noftrils  are  fluffed  with  thefe  powders  and 
oils  ;  and  incifions  ai-e  made  into  all  the  fiefhy  parts 
of  the  body,  which  are  alfo  fluffed  with  them,  and  af- 
terwards fewed  up  :  but  there  is  no  neceffity  for  this, 
unlefs  the  body  is  to  be  kept  for  a  great  length  of  time, 
or  to  be  carried  to  a  confiderable  diftancc.  In  which 
cafe,  it  is  ufual,  after  fluffing  the  incifions  in  the  man- 
VoL.  III.  M  m 


54^  Of  Embalming.  Chap.  LI. 

ner  I  have  mentioned,  to  roll  all  the  extremities,  as  tt 

well  as  the  trunk  of  the  body,  firmly  and  feparately  |j 

up  with  bandages,  and  to  cover  the  whole  with  var-  J 

nifh.  I 

The  body  is  now  to  be  laid  upon  a  cerecloth  of  a  ■* 

fufficient  fize,  which  mull  be  applied  with  as  much  i 

neatnefs  as  poffible  to  the  head  and  every  part  of  the  \ 

body,  and  either  firmly  fecured  by  fewing,  or  with  1 

tapes  tied  at  proper  diftances.     The  cerecloth  is  made  j 

of  linen  dipped  in  a  compofition  of  wax,  oil,  and  re-  1 

fin  ;  which  fliould  be  of  fuch  a  confiftence  as  to  be  fuf-  ij 

ficiently  pliable,  without  being  fo  foft  as  to  ftick  to  J 

the  fingers  of  thofe  who  apply  it :  it  may  be  coloured  j 

with  verdegris,  red  lead,  or  any  other  article,  accord- 
ing to  the  fancy  of  the  operator.     When  two  cere- 
cloths are  applied,  one  above  another,  they  are  ufual-  j 
ly  made  of  difTerent  colours.  j 

The  cerecloth  being  put  on,  It  was  formerly  the  cuf- 
tom  to  employ  a  painter  to  colour  the  face ;  but  this 
is  now  very  commonly  omitted :  the  drefs  intended 
for  the  corpfe  is  immediately  put  on ;  and  the  body  is 
either  laid  in  the  coffin,  or  allowed  to  be  expofed,  ac- 
cording to  circumftances. 


Chap.  LII,  .  Of  Bandages,  547 

CHAPTER    LII. 


OF  BANDAGES. 


BANDAGES  are  employed  for  various  purpofes 
in  furgery  ;  for  the  retention  of  dreflings ;  for 
(lopping  hemorrhagies  ;  for  removing  deformities ; 
and  for  effeding  the  union  of  divided  parts. 

As  a  proper  application  of  bandages  is  an  obje£l  of 
much  importance,  it  is  a  branch  of  the  art  which  au- 
thors have  not  negleded  :  many  treatifes  have  been 
publifhed  upon  it ;  but  unfortunately  it  cannot  be 
taught  by  defcription :  experience  alone  can  give  an 
adequate  idea  of  it ;  nor  is  it  poflible  to  acquire  it  but 
by  much  manual  praftice.  Hence,  in  the  ftudy  of 
this  part  of  furgery,  more  advantage  is  to  be  gained 
by  praftifmg  upon  a  block,  than  by  reading  the  mofl 
elaborate  diflertations.  My  only  intention,  therefore, 
at  prefent  is,  to  offer  a  few  general  obfervations  upon 
bandages. 

I .  Bandages  fhould  be  formed  of  fuch  materials  as 
are  fufficiently  firm  for  effeding  the  purpofe  for  which 
they  are  intended,  at  the  fame  time  that  they  may  fit 
with  eafe  upon  the  parts  to  which  they  are  applied. 

In  fome  cafes  a  degree  of  firmnefs  is  required,  which 
cannot  be  obtained  from  materials  of  a  foft  texture : 
of  this  we  have  examples  in  the  mofl  part  of  trulfes 
for  hernia;,  as  well  as  in  every  bandage  requiring  much 
elaflicity  :  but  for  the  mofl  part  bandages  are  made  of 
linen,  cotton,  or  flannel.  Till  of  late,  linen  was  uni- 
verfally  ufed  for  this  purpofe  ;  but  later  experience  has 
fhown,  that  cotton  and  flannel  are  preferable.  They 
abforb  moifture  more  readily,  whether  it  be  produced 
by  fweat,  or  as  the  ordinary  difcharge  of  wounds  or 


54S  Of  Bandages,    ,  Chap.  LII. 

fores,  at  the  fame  time  that  they  are  better  calculated 
by  their  elafticity  for  yielding  to  the  fwelling  which 
often  takes  place  in  luxations,  fraftures,  and  other  in- 
juries for  which  bandages  are  employed.  Flannel  was 
firfl  ufed  for  this  purpofe  in  the  Royal  Infirmary  here, 
about  forty  years  ago,  by  Mr.  James  Rae  of  this  place  ; 
and  fmce  that  period  the  pradice  has  been  generally 
adopted.  The  objection  made  to  the  ufe  of  flannel 
for  bandages,  by  fome  practitioners,  of  its  not  being 
fo  cleanly  as  linen,  is  frivolous :  neither  of  them  will 
be  cleanly  if  not  frequently  changed,  while  either  of 
them  will  be  fufficiently  fo,  if  this  point  is  attended  to, 

2.  Bandages  fhould  be  applied  of  a  degree  of  tight- 
nefs  fufficient  for  anfwering  the  purpofe  for  which  they 
are  intended,  without  incurring  any  rifk  of  impeding 
the  circulation,  or  doing  harm  in  any  other  manner. 
No  advantage  will  accrue  from  them,  if  the^  be  not 
fufficiently  tight  to  fupport  the  parts  aflected  ;  while 
fwelling,  inflammation,  and  even  gangrene,  will  occur 
if  they  are  too  tightly  applied. 

3.  Every  bandage  fliould  be  applied  infuch  a  man- 
ner, that  it  may  be  as  eafily  loofened,  and  the  parts 
examined  with  as  much  accuracy  as  poffible.  Thus 
in  fractures  of  the  thigh  and  leg,  where  the  limb  can- 
not with  propriety  be  frequently  raifed,  we  now  pre- 
fer univerfally  the  bandage  with  twelve  or  eighteen 
tails  to  the  common  roller.  The  former  can  be  un- 
done and  fixed  at  pleafure  without  moving  the  limb, 
"while  a  roller  can  neither  be  applied  nor  removed 
without  raifing  every  part  of  the  limb  to  a  confidera- 
ble  height. 

4.  Bandages  fhould  always  be  laid  afide  as  foon  as 
the  purpofe  for  which  they  are  intended  is  accomplifli- 
ed.  This  being  obtained,  no  advantage  can  accrue 
from  them,  and  they  often  do  harm  by  impeding  the 
growth  of  the  parts,  upon  which  they  are  applied. 

5.  I  have  found  it  neceflary  in  the  courfe  of  this 
work  to  mention  bandages  for  many  parts  of  the  body. 
In  fpeaking  farther  of  bandages  for  particular  parts  I 


Chap.  LII.  Of  Bandages,  549 

fhall  begin  with  the  head,  and  proceed  downwards  to 
the  trunk  of  the  body  and  extremities. 

One  of  the  beft  bandages  for  all  the  upper  and  back 
parts  of  the  head,  for  the  forehead,  ears,  and  temples, 
is  a  night  cap,  with  one  band  to  tie  it  before,  and 
another  beneath  the  chin,  as  is  reprefented  in  Plate 
CVII.  fig.  I.  The  couvre-chef  of  the  French,  repre- 
fented in  fig.  2.  is  moft  frequently  ufed  for  thefe  parts ; 
but  it  can  neither  be  applied  with  fuch  firmncfs  or 
neatnefs  as  the  night  cap. 

For  the  purpofe  of  making  compreffion  on  any  par- 
ticular part  of  the  head,  the  radiated  bandage,  as  it  is 
termed,  may  be  employed,  as  is  reprefented  in  the 
fame  Plate,  fig.  3.  It  may  alfo  be  ufed  for  comprelT- 
ing  the  temporal  artery  :  but  for  this  purpofe,  the 
fpring  bandage  reprefented  in  Plate  LXIV.  fig.  3.  an- 
fwers  better. 

In  longitudinal  culs  of  the  head,  the  uniting  band- 
age, as  it  is  termed,  is  ufed  with  advantage.  "It  is 
formed  of  a  long  roller  with  two  heads,  with  a  flit 
or  opening  in  the  middle,  as  is  reprefented  in  Plate 
CVIII.  fig.  3.  The  fides  of  the  cut  being  drawn  neat- 
ly together,  and  covered  with  a  pledget  of  any  fimple 
ointment,  the  cure  is  to  be  effefted  by  means  of  this 
bandage,  applied  in  the  manner  reprefented  in  fig.  6. 
of  the  fame  Plate.  In  cuts  of  this  defcription,  their 
edges  may  fometimes  be  retained  together  with  fuffi- 
cient  exadnefs  by  this  bandage ;  and,  when  this  caii 
be  done,  it  (hould  always  be  preferred  to  the  mod^f 
doing  it  with  futures.  ^• 

When  it  is  necelfary  to  retain  dreflings  upon  the 
eyes,  it  has  ufually  been  done  by  placing  a  comprefs 
over  them  and  retaining  it  by  feveral  turns  of  a  long 
roller,  fuch  as  is  reprefented  in  Plate  CVIII.  figure  i. 
This  bandage,  when  employed  for  one  eye,  is  the 
monoculus  of  authors,  and  it  is  termed  binoculus 
when  applied  to  both  eyes.  But  as  a  roller  palTed 
round  the  head  is  apt  to  flip,  even  when  applied  in  the 
moft  exa6t  manner,  the  couvre-chef  in  Plate  CVII, 


55^  Of  ^ajidagfs.  Chap.  LIT. 

figure  2.  or  the  night-cap  in  the  fame  Plate,  figure  i. 
Ihould  be  preferred. 

In  fradures  and  cuts  of  the  nofe,  the  dreflings  are 
bell  retained  by  a  proper  application  of  the  uniting 
bandage  in  Plate  CVIII.  fig.  3.  and  a  proper  applica- 
tion of  the  fame  bandage  anfwers  beft  in  longitudinal 
cuts  of  either  of  the  lips. 

In  fraftures  of  the  lower  jaw,  we  employ  a  four 
headed  roller,  fuch  as  is  reprefented  in  Plate  CVIII. 
fig.  4.  The  fpace  left  entire  between  the  four  heads 
is  applied  to  the  chin,  the  hole  in  the  centre  being 
meant  to  receive  the  apex  of  the  chin.  The  two  fu- 
perior  heads  are  then  carried  backwards ;  and  being- 
made  to  pafs  each  other  at  the  occiput,  they  are  after- 
wards brought  forward  over  the  os  fronfis  :  they  may 
either  be  fixed  there,  or  again  reflefted  back,  and  fix- 
ed with  pins  on  the  fides  or  back  parts  of  the  head. 
The  two  under  heads  of  the  roller  being  reflefted 
over  the  chin,  are  then  to  be  turned  upwards,  and 
either  tied  or  pinned  on  the  top  of  the  head  ;  or  be- 
fore fixing  them,  they  may  be  made  to  pafs  each  oth- 
er two  or  three  times.  Various  other  bandages  are 
defcribed  by  authors  for  the  head  ;  but  thofe  I  have 
mentioned,  with  a  proper  application  of  the  common 
roller,  Plate  CVIII.  fig.  i.  for  particular  purpofes,  are 
all  that  can  be  ever  required. 

6.  In  Plate  XCII.  fig.  i.  an  inftrument  is  deline- 
ated for  one  of  the  moll:  material  operations  upon  the 
nepk,  bronchotomy  ;  and  in  Plate  LIV.  fig.  i .  another 
is*  reprefented  for  the  wry  neck  :  a  common  roller 
may  be  made  to  anf\^'er  every  other  purpofe  that  can 
be  required  of  a  bandage  in  any  part  of  the  neck. 

7.  A  variety  of  bandages  are  ufed  for  the  fhoulders 
and  contiguous  parts,  particularly  for  fraftures  of  the 
fcapula,  and  fradures  and  luxations  of  the  clavicle. 
In  fraftures  of  the  fcapula,  a  proper  application  of  a 
long  roller  may,  in  mod  inftances,  prove  ufeful ;  but 
in  Chapter  XXXIX.  Section  V.  I  have  fhown,  that  no 
utility  is  derived  from  bandages  in  fractures  of  the 


Chap.  LII.  Of  Bandages.  551 

clavicles  :  they  cannot  be  applied  with  fuch  tightnefs 
as  to  comprefs  the  tVaclured  bone  without  impeding 
refplratlon  ;  and  befides,  we  do  not  find  that  they  are 
necefTary,  when  the  arm  of  the  affected  fide  is  proper- 
ly fupported  by  the  fling,  Plate  XCVI.  fig.  2. 

The  mofl  uieful  of  all  bandages  for  the  thorax  and 
abdomen,  at  lead:  for  the  retention  of  dreflings  on  any 
of  thefc  parts,  Is  that  which  we  ufually  term  the  nap- 
kin and  fcapulary,  reprefented  in  Plate  CIX.  figure  i. 
That  part  of  it  which  goes  round  the  body  A,  is 
termed  the  napkin.  When  applied  for  making  pref- 
fure  upon  a  fradured  rib,  it  fliould  be  in  the  form  of 
a  roller,  and  fliould  pafs  two  or  three  times  round  the 
body  :  when  only  ufed  for  retaining  drefllings.  It  fliould 
not  go  more  than  once  round  :  It  fliould  be  fix  or 
feven  inches  broad  for  an  adult ;  and  fecured  by  piec- 
es of  tape,  tying  it  at  each  end,  infl:ead  of  pins.  The 
fcapulary  B  C,  confiflis  of  a  flip  of  linen,  cotton,  or 
flannel,  about  three  inches  broad,  and  of  a  length  fuf- 
ficient  to  reach  from  the  upper  part  of  the  napkin  be- 
hind, to  pafs  over  the  flioulders  and  be  pinned  to  it 
before  :  it  is  fometimes  made  with  a  hole  In  the  cen- 
tre for  pafling  over  the  head  ;  but  it  anfwers  better  to 
divide  the  anterior  end  of  it  by  a  longitudinal  flit  in- 
to two,  and  In  applying  It,  to  make  one  of  thefe  flips 
pafs  on  each  fide  of  the  neck. 

This  bandage  anfwers  the  purpofe  better  than  any 
other,  for  making  preflure  on  the  parts  at  which  the 
vifcera  protrude,  in  umbilical  and  ventral  hernlse.  As 
in  fuch  cafes  it  is  a  point  of  much  importance  to  have 
the  bandage  firmly  fixed,  we  not  only  employ  the 
fcapulary  for  preventing  it  from  flipping  down,  but  a 
fl:rap  connected  with  It  behind  is  p:^fled  between  the 
thighs,  and  pinned  to  it  before,  to  prevent  it  from 
flipping  up. 

In  Plate  XCI.  fig.  1.  a  bandage  is  reprcilnted  for 
comprefling  the  abdomen  in  the  operation  of  tapping  ; 
and  in  Plate  LXV.  different  bandages  arc  delineated. 


552  Of  Bandages.  Chap.  LII. 

or  trufles,  as  they  are  termed,  for  the  retention  of  the 
protruded  vifcera  in  cafes  of  hernia. 

9.  As  it  is  of  much  importance  in  various  difeafes, 
as  well  as  in  feveral  operations,  to  have  the  fcrotuni 
properly  fupported,  I  have  delineated  fome  bandages 
for  this  purpofe  in  Plate  CX.  The  bed  bandage  for 
the  penis  is  a  pouch,  or  bag  of  linen  or  cotton,  to  be 
fixed  by  a  roller,  or  two  pieces  of  tape  paffed  round 
the  body. 

The  T  bandage,  as  it  is  commonly  termed,  Plate 
CIX.  figures  3.  and  4.  is  ufually  employed  for  the  re- 
tention of  dreffings  about  the  anus  and  perineum,  as 
well  as  for  fome  diforders  of  the  fcrotum  ;  but  in  the 
laft,  one  or  other  of  the  fufpenfory  bandages,  repre- 
fented  in  Plate  CX.  will  for  the  mod  part  be  found 
preferable. 

10.  In  compound  fradures  of  the  arm,  fore-arm, 
or  hand,  where  motion  of  the  limb  would  prove  hurt- 
ful, the  twelve  or  eighteen  tailed  bandage  is  equally 
proper  as  in  fimilar  affections  of  the  lower  extremities ; 
but  in  fimple  fradures,  as  well  as  in  almoft  every  oth- 
er affeftion  of  thefe  parts,  we  prefer  a  proper  applica- 
tion of  the  roller. 

1 1 .  I  advifed  the  uniting  bandage  for  longitudinal 
cuts  in  the  head  ;  it  anfwers  equally  well  in  wounds 
of  a  fimilar  nature  in  every  part  of  the  extremities,  a« 
is  reprefented  in  Plate  CVIII.  fig.  6. 


END  OF  VOLUME  THI.H.D. 


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Date  Due 

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1 

L.  B.  Cat.  No.  1137 

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Bell 
A   Syj 

B'tc^o                         43516 

stem  of  Surgey 

°^"^=  DUt                                        ISSUED  TO 

1 

617     B433 


43516 


